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GUIDE 



Examination of Urine, 

WITH SPECIAL REFERENCE 

TO THE 

of the URINARY APPARATUS 



K. B. HOFFMAN, 

Professor at the University 



R. ULTZMANN, 

Doeent at the University 



OF VIENNA. 



SECOND EDITION. 

TRANSLATED AND EDITED BY 

F. FORCHHEIMER, M. D., 

PROFESSOR OF PHYSIOLOGY AT THE MEDICAL COLLEGE OF OHIO, 
CINCINNATI. 



WITH ILLUSTRATIONS. 



CINCINNATI: 

WOODRUFF, COX # CO., Publishers, 72 West Fourth Street. 
1886, 




#„, 



fc 6 5 



in 



COPYRIGHT 

1886. 

WOODRUFF, COX & CO. 



Tttt Gftk?W\C PRS.SS. C\N , 0. 



PREFACE, 



In bringing this little work before the medical pub- 
lic, the translator has been encouraged by the fact of 
its popularity on the Continent, and its nearly uni- 
versal adoption by the German high-schools. Now 
that the second German edition has appeared, consid- 
erably altered from the first, as well as enlarged, he 
no longer hesitates in bringing it before the profession 
of this countpy. As the authors state in the preface 
to the first edition, this book is not intended for the 
physiological chemist, nor for him who is going to 
make animal chemistry a specialty; neither does it 
supply the place of many larger works, such as exist 
in the English language. Every test, every method, 
is brought home to the student and physician for use 
in practice. A great amount of space and time is spent 
upon methods, showing how an examination of urine 
and diagnosis of disease can be most readily and 
quickly made. The book, in every respect, is fully up 
to the times, for which the names of the authors alone 
are sufficient guarantee. 



PREFACE. 

The office of the translator has been not only to 
translate, but, also, in several places, to make slight 
additions or omissions, being guided therein by his 
experience as teacher of urinalysis in the Medical 
College of Ohio. In addition, he has supplied the il- 
lustrations, that have been drawn by his student, Mr. 
W. S. Christopher, and which, he hopes, will make 
the book more attractive as well as more instructive 
than it would have been ixi the German form. 

" May the endeavors to increase the utility of this 

work not be without result." 

F. F. 



PREFACE TO THE SECOND EDITION. 



Comparison with the first edition of this work will 
show that very many changes have been made. The 
greater part of the translation has been entirely 
rewritten. The plates have all been retained, not 
because of their artistic merit, but because they have 
seemed to me to show what was wanted in order to 
bring out certain points. The index is entirely new, 
and has been written for the special purpose of 
making the book one that can be easily referred to. 
The flattering reception of the first edition, faulty 
as it was, leads me to believe that this, the second, 
with more notes and in its new form, will take that 
rank which the original deserves. 

F. FORCHHEIMER, M. D. 



INTRODUCTION. 






The complicated processes which go to make up 
the basis of organic life result on the one hand, in 
the building up of the body, and on the other, in 
changes which have been collectively termed "ret- 
rograde metamorphosis," an elimination of effete 
substances (which can no longer be utilized by the 
economy) ; either by the skin and lungs, principally 
in the form of gas; or by the intestinal tract and kid- 
neys, in the form of solids, or in solution. 

To obtain a correct conception of normal or abnor- 
mal nutrition, examination must be made into the 
functional activity of these organs, as well as its re- 
sults, their excrementitious matter. In the healthy 
condition of the organism this is exceedingly difficult; 
in disease of any significance, it is simply impossible. 
The physician is compelled to restrict his studies, 
therefore, to one of these excretions — the urine — the 
most important, fortunately, since by means of quali- 
tative and quantitative changes, it registers, at least 
approximately, the variations in the life of tissues. 

Examination of the urine offers this additional 
advantage, the fluid can be collected without diffi- 
culty, and its analysis, so far as it interests the prac- 
ticing physician, can be carried out by very simple 

means. 

(i) 



2 INTRODUCTION. 

Not being a lifeless filtering apparatus, the kidney 
is subjected to disease, to pathological changes, and 
as a result, substances are mixed with the urine, whose 
presence alone will lead the physician to a diagnosis 
of the disease. The urine, then, gives us an insight 
into the condition, not only of the urinary apparatus, 
but of the whole body. 

On account of the fact that many substances have 
the peculiar faculty of leaving the system by means 
of the kidneys, it may be casually stated here that the 
urine is of great importance to the pharmacologist, 
and, in some instances, to the medico-legal expert as 
well as to the physician. 

The desire to recognize disease from the appearance 
of the urine dates from the most remote past of scien- 
tific medicine. In his precise and objective observa- 
tion of the sick, Hippocrates did not disregard its 
changes. 

He instructed his pupils, in accordance with the 
condition of other sciences, in the semiotic and the 
prognostic importance of these changes. He demon- 
strated the physical properties of urine ; its quantity, 
color, and clearness, its cloudy or turbid appearance, 
and the apparent differences in its sediments, referring 
these to diseases of the urinary apparatus. Whilst 
his explanations for these appearances may be very 
unreasonable, his observations were in the main cor- 
rect, and led him to conceive the influence of food 
and drink upon the condition of the urine, which he 
endeavored to show. 

In the post-hippocratic descriptions of disease, we 



INTRODUCTION. 6 

find the condition of the urine taken into considera- 
tion, but the followers of the great Coic physician 
added nothing to his views. Galen developed these 
teachings, and systematized them, after which their 
infallibility was not questioned. But for a long time, 
no progress was made in this direction, and through- 
out the following centuries we scarcely find one author, 
who. through personal observations, has added to these 
transmitted treasures. 

To the Arabian, Iben Sina — 980-1037, — usually 
called Avicenna, belongs the credit of having pointed 
out the fact that external causes (such as fasting, 
vigils, physical and mental exertions) influence the 
condition of the urine. It was he also, who demon- 
strated that drugs, taken internally, may cause its 
temporary discoloration. Beyond this, Arabic phy- 
sicians did nothing of importance on this subject, not- 
withstanding the presence of an uroscopist at every 
oriental court. 

In ancient times, and during the middle ages, 
certainly no one attained such prominence in this 
specialty, as one Johannes, called Actuarius, who lived 
in the thirteenth century at the court of Byzantium. 
Adding his own experience to the work of the Hip- 
pocrates-Galen school, Johannes describes the phys- 
iological changes in urine most minutely, in the 
seven books of his work "irepl ovpuv" which are con- 
spicuous for method and clearness of description. 
This production, which exhausted the possibilities of 
the allied sciences as they then existed, and the inade- 
quate methods at their command, remained isolate, 



4 INTRODUCTION. 

and our division of symptomatology was more and 
more neglected in the time which followed. That 
it furnished material for satirical representations in 
Dutch genre pictures, as well as for many comedies of 
Moliere and other poets, is sufficient proof of its de- 
generation. 

Up to this time all conceptions of the chemical com- 
position of urine were highly defective, so that exter- 
nal appearances alone could be considered by authors 
of the age. Real progress could only be expected from 
an adequate development of chemistry and its methods 
of examination; with Lorenzo Bellini, of Florence, 
this progress begins. Bellini evaporated urine, and 
observed that as he again added water, the solids 
dissolved, returning gradually, step by step, through 
various intensities of taste and color, almost to the 
original condition. From this he concluded that the 
different color ahd taste of urine depended upon the 
relation the solid constituents bore to the water, a con- 
clusion upon which, even now, Vogel's scale of colors 
is based. 

Many important chemical discoveries followed soon 
after this. Willis discovered sugar in urine ; Brandt, 
phosphorus, which, Markgraff stated, came from the 
phosphates that were contained in the urine. 

Rouelle, the younger, discovered urea in 1773, and 
found that calcium carbonate was present in the urine 
of herbivora, as well as a substance similar to the 
flowers of benzoe (hippuric acid). In 1770, Cotugno 
found albumin in urine; in 1798, Cruikshank con- 
nected this discovery with dropsy, and, in 1807, Bright 



INTRODUCTION. O 

finally demonstrated the connection between diseased 
kidneys and albuminuria. 

At the same time, chemical analysis of gravel and 
calculi were undertaken. Among the many publi- 
cations of merit on this subject, those of Scheele, 
Wollaston, Wetzlar, and Prout must be especially 
mentioned. 

To two Frenchmen, however, is due the credit of 
having developed uroscopy to its present position. 
The researches of Rayer, as shown in his large work, 
" Les maladies des reins," form the foundation for our 
present knowledge of kidney diseases. 

Becquerel, the son of the celebrated physicist, had 
for a long time occupied himself with urinalysis, 
under the direction of Andral, and modestly gives 
him all the credit of having inspired him with the 
thoughts for his observations. These observations 
having extended through many years, he finally pub- 
lished them in the work "Semiotique des urines." 
For the thirty years following the appearance of this 
book, many students have devoted themselves to the 
same branch, so that probably no other division of 
zoochemistry has so extensive a literature as this. 

After this short sketch of the development of our 
subject, there remains only a brief discussion of the 
divisions that have been thought necessary for this 
book. 

After a chapter on the microscopic structure and 
function of the urinary organs, [without a knowledge 
of which, comprehension of disease is an impossibility,] 
the physical character and chemical constituents of 



6 INTRODUCTION. 

urine, as far as they seem to us important to the practising 
physician, are treated of. Upon this follows a descrip- 
tion of the microscopical part, i. e., the sediments. 

Reviews will be of advantage to the beginner, for 
whom this little work is intended. The short key to 
the method of examination he will also find of value. 
Finally, a description of the simple (uncomplicated) 
diseases of the urinary organs will be found, in so far 
as they give signs that can be utilized for diagnosis. 



CHAPTER I. 



HISTOLOGY OF THE URINARY APPARATUS. 

I. The Kidney.* 

If a kidney be cut from the papilla* to the fibrous 
capsules, two concentric layers will become distinctly 
visible to the naked eye: the central, striped medulla, 
and the peripheral, more granulated cortex. If the 
blood-vessels and uriniferous tubules be injected with 



Fig i. 
A longitudinal section of the kid- 
ney of a dog : blood-vessels and urin- 
iferous tubules injected. 



different coloring matters, 
other divisions may be 
seen. 

p, Papillary portion, and (/, 
1 )oundary zone of the mednlla ; 
the dark rays, 7i, are bundles 
of uriniferous tubules, which 
are continued, m } into the 
cortex, and the unshaded di- 
visions of the medullary layer, 
b, correspond to the bundles 
of blood-vessels of the bound- 
ary zone, r, Is the cortex, or 
cortical layer ; m, the continu- 
ation of the uriniferous tu- 
bules of the medullary layer, 
and c, the unshaded part of 
the cortex occupied by dots 
(glomeruli), represents the 
labyrinth (after Ludwig). 
The investigations of Kolliker, Schweigger-Seidel and Ludwig were 
taken hs a basis for this description of histological relations. 

(7) 




O EXAMINATION OF THE URINE. 

In the papilla, and in the neighborhood above it, 
the kidney seems to be uniformly radiate, colored only 
by the mass injected into the urinary tubes; this divi- 
sion is called the papillary zone of the medulla. 
Above this there is a section which is also radiate, but 
beginning to show the mass injected into the blood- 
vessels. There can here be seen alternate layers of the 
injected masses. This part is called the boundary 
zone of the medulla. The third, outer layer, finally? 
which encloses the others, is known as the cortical 
layer, and it shows narrow stripes of the tw r o injected 
colors, in alternate arrangement. Those colored by 
the mass injected into the uriniferous tubes are the 
direct continuations of the fibres of the medulla, and 
are called medullary rays. To the others (showing 
granules principally, seemingly colored by the mass 
injected into the blood-vessels), has been given the 
name of labyrinth, or cortical layer in the strict sense. 

Accordingly, we find through the misroscope that 
the papillary layer is made up chiefly of straight 
uriniferous tubules ; the boundary zone, of these and 
blood vessels ; the pyramids, principally of the straight 
uriniferous tubules, and the labyrinth, of convoluted 
tubules, and of convoluted and tortuous blood-vessels. 

This system of blood-vessels and uriniferous tubules 
is supported by connective tissue, which forms a very 
sparse stroma. It consists of a fine network of con- 
nective tissue corpuscles, and is better marked in the 
medullary layer than in the cortical. Upon the surface 
of the kidneys the stroma is condensed into a delicate 
membrane, which is only loosely connected with an 



THE KIDNEY. 9 

outer fibrous, investing membrane, surrounding the 
whole kidney, and attached at the hilus to its vessels 
and the pelvis. This investing membrane is made up 
of ordinary connective tissue, with a dense, fine, elastic 
network. 

The Uriniferom Tubule originates in the labyrinth, in 
the form of a spherical dilatation (Capsula Malpighii).* 
"Then, through a contraction (the neck of the capsule) 
it progresses in the form of a dilated tube, which takes 
its course in manifold curves toward the medullary 
portion. When this large convoluted tube reaches 
the boundary zone, it contracts and penetrates more 
or less deeply, as a straight narrow canal (descending, 
or closed limb of the loop) into the medullary substance, 
turns back, making a narrow loop {Heinle's loo})), and 
runs directly upward, towards and into the cortical 
substance (ascending , or open limb of the loop). 1 '* "Upon 
returning to the cortex, the tubule, instead of seeking 
the exact place from which it came, seems to avoid the 
labyrinth and creeps close to the nearest bundle of 
medullary rays. Sooner or later, however, it abandons 
its straight course, enters the labyrinth, as the so-called 
intermediate portion, and proceeds, in more or less 
angular curves, between the tortuous canals. Soon it 
turns again, forming an arch whose convexity is 
directed towards the convexity of the kidney, towards 
the medullary rays, there to abandon its individual 
existence in a union with several other converging 
tubules into one larger and straight tube (collecting 
tubule)" 

This quotation is taken from the classic description of C. Ludwig. (Hand- 
book of Histology. Strieker.) 



10 



EXAMINATION OF THE URINE. 



a uriniferous tube ; human kidney. 



Such a collecting tubule holds a straight course 

until it reaches the papillary portion of the kidney, 

Fig 2 . where it unites dicho- 

Schematie representation of the course of tomOUSiy, from time 

to time, with neigh- 
boring collecting tu- 
bules, until finally it 
empties itself (ductus 
papillaris) upon the 
surface of the papilla. 

p, Papillary layer; g, 
boundary zone of the 
medulla; r, cortical sub- 
stance ( I ), capsule of 
glomerulus, which enters 
into tortuous portion 
(II), through its neck. 
The tortuous portion con- 
tracts at # the boundary 
between medulla and 
cortical, into (III) the 
descending limb of the 
loop, and as such, goes 
through (h) Henle's loop, 
into (IV), the ascending 
limb of the loop. To this 
is added (V), the inter- 
mediate portion, which 
through (r) the external 
/ P loop at the top, enters the 
collecting tubule., The 
collecting tubule unites 
with (VII) its neighbor 
of the same medullary 




THE KIDNEY. 11 

ray to form (VIII) the principal tube, and this in turn unites 
with others until it finally forms (IX) the ductus papillaris. 

The walls of the Malpighian capsule are made up of 
mosaic cells, like those of blood and lymph capillaries. 
The external surface, or tuft, of the glomerlus is cov- 
ered by a layer of cells, containing spherical nuclei, 
and not distinctly separated from each other, which 
prevent its being washed directly by the fluid contents 
of the capsule. 

"From the neck of the capsule to the commence- 
ment of the papillary duct, the wall of the tubule is 
composed of a tunica propria, and a layer of epithe- 
lium resting upon its inner surface." The tunica 
propria is homogeneous, transparent and elastic. The 
epithelium, which invests the inner surface, consists 
of one layer, which is possessed of nuclei, w r hose form 
is everywhere the same; spherical and sharply defined, 
and whose contents show many granules. The body 
of the cell, on the contrary, varies largely in shape. 
In the arched, tortuous tubules the epithelium forms 
a collected, gelatinous, cloudy mass, in which nuclei 
are imbedded at equal distances from each other; a 
division into cells corresponding to these nuclei, seems 
to be entirely absent. 

a This epithelial pulp sits very loosely upon the 
basal membrane," and the w r hole substance can be 
easily forced out of the cut tubules in the form of a 
cylindrical mass. With the microscope, this is found 
to contain many oil globules, as well as other dark 
corpuscles (cloudy swelling of the epithelium), which, 
upon the addition of dilute acid, are cleared up; but, 



12 EXAMINATION OF THE URINE. 

after being thus cleared, it is often impossible to dis- 
tinguish anything, except the nuclei of the cells in the 
mass. 

In the small tubules, which form the limbs of the 
loop of Henle, there appears, instead of the dark and 
bulky epithelium already described, a light and meager 
one, covering the walls of the tubule, with a contin- 
uous layer of cells, which are much bulged out by the 
nuclei. 

Beyond Henle's loop, where the diameter of the tube 
increases, the epithelium appears to consist entirely of 
cylindrical cells, arranged like the shingles of a house, 
the one above the other, and following the direction 
of the tube, from the medullary to the cortical layer. 

The gelatinous layer, which is common to the tor- 
tuous canals, is again found in the intermediate por- 
tion. 

In the collecting tubules, including the papillary 
duct, the epithelium is composed of distinctly separ- 
ated cylindrical cells, with their bases upon the tunica 
propria, and their blunted points toward the lumen of 
the tube.* 

*[B. Heidenhain (Handbuch der Physiologic Hermann, Bd. V. p. 284-288), 
who, for over ten years, has been able to distinguish differential markings 
pi cells, describes the lining of the uriniferous tubules, as follows : 

In the tortuous canals he finds epithelial cells of a peculiar character; 
their protoplasm cousists of fibrils or rods agglutinated by unchanged pro- 
toplasm. They form a broadened base, which rests upon the membrana 
propria, and towards the lumen of the tubule they end in undifferentiated 
protoplasm which surrounds the cell nucleus. This undifferentiated pro- 
toplasm is continuous with that forming the cement substance of the rods. 
Some of the rods seem to pass the unclear zone, but they never reach the 
lumen of the canal. In the descending limb of Henle's loop, the epithelium 
consists of very flat spindle-shaped cells, with badly-defined outlines, whose 
nuclei project far into the lumen of the canal. In the ascending limb of the 



THE KIDNEY. 13 

Blood-Vessels of the Kidney. — The renal artery sends 
the greater part of its blood through the cortical por- 
tion. Its branches penetrate to the boundary of the 
cortex without forming a network, and then rapidly 
divide into very minute arteries; the arteriolae inter- 
lobularis and arteriolar rectte. The interlobular arter- 
ies run between two medullary rays, i. e., where sev- 
eral primitive bundles are found together. Arrived 
in the layer of tortuous tubules, they give off' a branch 
to each Malpighian capsule. This branch (Vas afferens 
glomeruli) perforates the spherical end of the tubule 
(or, according to other authorities, pushes the same 
before it), and here terminates " in a pendulous bundle 
of capillaries (glomeruli), which in their turn, are 
collected within the capsule, into one venous branch 
(Vas efferens glomeruli).'' 

This venous radical comes out of the capsule at the 
place where the artery enters it. After leaving the 
capsule ki it proceeds toward its medullary ray; or, 

loop the epithelium is the same as in the tortuous canals, differing only in 
the length, both absolute and compared to the size of the cells, of the rods. 
In the intermediary portions th*at have the same diameters as the tubuli 
eontorti, are found highly refractive cylindrical cells, with large nuclei and 
a small amount of protoplasm. Where the cell rests upon the tunica 
propria the protoplasm spreads, so as to form processes which lie upon 
processes coming from neighboring cells. In intermediate tubes of smaller 
diameter the epithelium is lower. In the collecting tubule, within the 
medullary ray, are found cells approaching the cylindrical in type, but 
presenting the same peculiarities as described in connection with those of 
the intermediate portions of large diameters. As we descend, we find typical 
columnar epithelium, becoming higher the nearer we approach the papil- 
lary duct. Heidenhain divides the uriniferous tubule into two portions — 
the secretory and the efferent. The secretory portion consists of those 
parts included between the Malpighian tuft and the beginning of the 
medullary; the efferent, those between the beginning of the medullary 
ray and the opening of the ductus papillaris."] 



14 EXAMINATION OF THE URINE. 

where this is lacking (as in the outermost layer of the 
cortical substance), directly to the tortuous tubules, 
and splits up into a number of capillaries, which im- 
mediately combine to form a network," thus producing 
meshes which surround the uriniferous tubules. All 
the efferent vessels communicate with each other by 
means of their capillaries, forming a continuous capil- 
lary network, which occupies the whole cortical sub- 
stance; this, in its turn, anastomoses with the meshes 
around the pyramids, and a connection is thus estab- 
lished between the capillaries of the medullary and 
cortical portions. 

Venous trunks are formed by these capillary nets. 
In that part of the cortical in which no glomeruli are 
found, the veins originate in the form of stars (Venae 
stellatse). The common trunk penetrates that part of 
the cortex which is supplied with tufts and tubules, 
seeks the neighborhood of an interlobular artery, where 
it takes up many veins from the surrounding cortical 
portion. 

The veins of the medulla (venule rectse)' run in 
those spaces which are occupied by the arteries, and 
unite at the border of the cortex, with the veins com- 
ing from the latter, to form large trunks. 

The capsule of the kidney receives its blood-vessels 
partially from the interlobular arteries, and partially 
from other neighboring trunks (the phrenic, lumbar 
and supra-renal arteries). Some of their capillaries 
enter the stellate veins ; some enter veins correspond- 
ing to the arteries that have supplied the blood. 

The Nerves of the kidney are derived from the 



THE BLADDER. 15 

coeliac plexus of the sympathetic. They follow the 
course of the larger vessels, as well as the lymphatics 
that enter the lumbar glands. Their final termina- 
tions are not known. 

II. Efferent Passages. 

The Ureters, Pelvis of the Kidney and the Calyces are 
made up of an external fibrous membrane, a layer of 
unstriped muscular tissue, and a mucous membrane. 
The fibrous coat is continuous with the albuginea of 
the kidney, and consists of connective tissue and 
elastic fibres. In the ureters, the muscular layer is 
made up distinctly of three divisions : the inner one 
runs longitudinally, the middle one transversely, and 
the outer, which is the thinnest, again longitudinally. 
In the pelvis the relations are the same, except that 
in the calyces the muscular layers become thinner 
and finally disappear where they touch the papillae. 
The mucous membrane is thin, rather rich in blood- 
vessels, without glands or papillae. The epithelium is 
present in layers, and is characterized by the varied 
form and size of its elements. In its deep layers, the 
cells are round and small ; in the middle layers, cylin- 
drical or spherical, with prolongations; and at the 
surface, rounded, many cornered, or frequently flat- 
tened, and of larger size. 

The Bladder possesses the same membrane as the 
ureters. The muscular layer is frequently quite thick, 
but the individual fibres are distributed so irregularly 
that their schematic course cannot be described. In- 
ternallv there is usually found a net of circular bun- 



16 EXAMINATION OF THE URINE. 

dies which cross each other at acute angles, thus 
forming meshes which lie transversely. These circu- 
lar fibres are thickest at the opening of the bladder, 
and there form its sphincter. Upon these circular 
bundles, follow longitudinal fibres which are of in- 
constant distribution. The trigonum consists simply 
of a thickening of the connective tissue layer, ex- 
tending from the opening of the ureter to the caput 
gallinaginis. The mucous membrane (except at the 
trigonum), especially at the neck and fundus of the 
bladder, has a thick sub-mucous layer, which is rich 
in blood-vessels and nerves. 

At the neck of the bladder, and towards the fundus, 
are found simple racemose glands, having cylindrical 
epithelium and mucous contents. 

In the bladder the epithelium is found arranged in 
several layers. Innermost are found cells of a de- 
cidedly flattened form, but differing largely both as to 
size and shape, the one from the other. The middle 
layer is usually composed of young conical cells, with 
their apices tow r ard the cavity of the bladder, and 
whose processes can be frequently traced into the 
deeper layer. The outer layer is made up of ovoid 
cells; irregular, and frequently drawn out, where they 
are in contact with the middle layer. 

The superior and inferior vesical arteries (branches 
of the hypogastric) supply the bladder with blood. 
They pierce the wall of the bladder at the fundus, 
pass obliquely through the muscular coat, giving off 
branches to the same, and then divide into capillaries 
in the connective tissue under the epithelium. 



THE URETHRA. 17 

In the connective tissue at the fundus, nerve fibres 
are not very numerous, but the medullary sheath can 
be detected in all of them; their terminal branches 
are not known. The vessels and nerves of the ureters 
are analogous to those of the bladder. 

The Male Urethra has a corpus cavernosum whose 
structure is like that of the penis, fibrous membrane 
and meshes, only much more delicate; and a glandu- 
lar organ — the prostate gland, which forms its sup- 
port. Under the mucous membrane, throughout its 
whole extent and below it, there is a well developed 
connective tissue layer, rich in elastic fibres ; there are 
also to be found here organic muscular fibres, arranged 
both longitudinally and transversely. 

The epithelium of the male urethra is cylindrical 
and arranged in layers ; with the exception of the ex- 
terior part of the fossa navicularis, where papillae and 
flat epithelium are already to be found. The cells of 
the accessory glands, those of the prostate, Cowper's 
and Littre's glands, and of the vesicula prostatica are 
conical and can hardly be distinguished from those of 
the urethra. 

The Female Urethra has no corpus cavernosum; its 
mucous membrane is rich in vascular supply, and 
has flat epithelium in layers. In addition there are 
very few glands of Littre to be found in it. 



k. it.- 



18 EXAMINATION OF THE URINE. 



CHAPTER II. 

Secretion of the Urine. 

The function of the kidney is to secrete the urine : 
that of the bladder and ureters, on the other hand, to 
collect, retain, and carry it off. A theory which is 
entirely satisfactory, and explains all facts concerning 
the secretion and excretion of urine, does. not, as yet, 
exist. 

Bowman, basing his views upon the anatomical 
structure of the kidneys, thinks that the epithelial 
cells are secretory organs, and that w r ater only is ex- 
creted by the tufts, which washes the constituents of 
urine out of the epithelial cells. 

Ludwig bases his theory, on the one hand, upon 
the different amount of blood pressure in the various 
blood-vessels of the kidney; on the other, upon the 
different capacity that substances possess of passing 
through animal membranes. He assumes that the 
pressure upon the glomeruli is greater than in the 
capillaries surrounding the uriniferous tubules. As a 
result, an abundant transudation of water and salts 
in solution, (serum of blood, little albumin and fat) 
must take place from the blood into the Malphigian 
capsule. Thus, very dilute urine is to be found in 
the uriniferous tubules, and highly concentrated 
blood, in the capillaries surrounding the tubule. 



SECRETION OF THE URINE. 19 

These two fluids, differing so widely in density, and 
separated from each other by animal membrane, pro- 
duce active currents of diffusion : as a result, water is 
added to the concentrated blood, on the one side, and 
on the other, products of retrograde metamorphosis 
(urea) and salts, are added to the dilute urine in the 
uriniferous tubules. In this way the watery urine 
becomes more concentrated, richer in urea and salts; 
becomes urine. The absence of albumin is to be ex- 
plained, in that this substance does not easily pass 
through animal membranes, and then only as a result 
of increased pressure (the walls of the blood-vessels 
and tubules are animal membrane) : accompanying 
pathological conditions, with increased pressure in the 
glomeruli < stasis in the veins of the kidney) albumin 
is always found in the urine, but under normal pres- 
sure this is never the case. Although this theory 
explains many physiological and pathological facts, 
yet it does not explain how an alkaline serum of the 
blood produces an acid urine. According to this 
mechanical theory of Ludwig. the secretion of urine 
is a process of filtration taking place in the glomerulus 
and a process of diffusion throughout the course of 
the tubules; the epithelial cells lining the tubules are 
not taken into consideration at all. 

According to Goll and Max Hermann, the difference 
in pressure between the contents of the vessels and 
urinary tubules, is the principal. force that causes the 
transmission of the constituents of the urine from the 
blood to the tubules. According to this, when pres- 
sure is increased in the renal artery the quantity of 



20 EXAMINATION OF THE URINE. 

urine immediately increases; but when the pressure 
in the artery is diminished, or when pressure in the 
ureters is increased, blood pressure remaining normal, 
secretion diminishes, and may cease entirely, long 
before the pressure in the ureters equals that in the 
renal artery. 

Ustimowitsch and Grutzner have elaborated this 
theory, in so far that they showed by experiments 
on . dogs, that the local pressure in the glomeruli 
only, not the general blood pressure, must be taken 
into consideration. 

Upon section of the medulla in a dog, and electric 
irritation of the same producing increased blood 
pressure, secretion of urine ceased entirely, because 
the smaller vessels of the kidney contracted. If, in 
addition, the nerves going to one of the kidneys were 
divided, there would follow on that side a profuse 
flow of urine, whilst on the other no urine would 
flow from the ureter. By means of division of the 
nerves going to the kidneys, its smallest arteries be- 
come dilated and relaxed, thus increasing pressure in 
the smaller vessels and stimulating the flow of urine. 

In addition, Ustimowitsch demonstrated that an in- 
crease in secretion of urine can take place, even when 
the general blood pressure is diminished. If the 
splanchnic nerve (which contains the vasomotoric 
tracts for the kidney) be divided, the pressure in the 
aorta is diminished ; at the same time, however, dila- 
tation of the smaller arteries in the kidney ensues, so 
that an increase in secretion can be verified. 

Heidenhain and Wittich support Bowman's views 



SECRETION OF THE URINE. 21 

concerning the secretive function of the epithelium 
in the tortuous uriniferous tubules, for they show by 
experiments with indigo sodium sulphate, sodium 
urate and ammonium carminate, that these sub- 
stances are principally secreted by this epithelium. 

According to the experiments of K. Muller, the 
quantity of urine is increased by the action of cold 
upon the skin ; and is decreased by warm baths, or 
varnishing the surface of the body, the latter pro- 
ducing dilation of the blood-vessels in the skin. 

An increase in the circulation of the skin, then, in- 
creases: a diminution of the same, decreases, the 
secretion of urine. 

Malv. Donath and Posch claim that an aqueous 
solution of various salts, having a neutral or even an 
alkaline reaction (mono and di-sodium phosphate), 
may. when subjected to osmosis, produce a solution 
of acid reaction. This is exceedingly important, be- 
cause it obviates the necessity of ascribing to the 
epithelial cells the property of causing the formation 
of acid. 

As all the physiological and chemical processes 
which take place during the secretion of urine are not 
completely explained by the hypotheses thus far 
brought forward, we must still look upon this process 
as a combination of secretion and filtration. 



22 EXAMINATION OF THE URINE. 

CHAPTER III. 

THE URINE. 

A. — In General. 

Urine is the secretion of the kidney, and in the 
normal condition, represents, in the main, a solution 
of the substances which result from retrograde meta- 
morphosis. 

It is a solution of urea and common salt, to which 
are added, in small quantities, other organic and in- 
organic constituents of the blood; also, certain sub- 
stances introduced into the system, which are excreted, 
either in their unchanged condition, or after having 
undergone a chemical decomposition. 

Normal urine contains as organic constituents ; urea, 
uric acid, creatinin, hippuric acid, xanthin, lactic 
acid, grape sugar (Briicke), etc. : inorganic constit- 
uents; sodium chloride, sodium, calcium, and magne- 
sium phosphate, sulphates of the alkalis, ammonium, 
and iron salts, combined with coloring matter and 
gases; carbon di oxide, nitrogen and oxygen. 

In pathological urine there can be detected, in addi- 
tion to these normal substances, albumin, grape sugar, 
inosit, constituents of bile, fats, hydrogen bisulphide, 
blood coloring matter, uroerythrin (Heller), leucin and 
tyrosin, calcium carbonate and oxalate, ammonium 
carbonate, cystin, pus, blood, epithelial structures, 
spermatoza, fungi and infusoria. 



PHYSICAL PROPERTIES. 23 

B.efore considering the symptom atological value of 
urine, we must look at its properties(as far as they 
interest us), and the most valuable methods for its 
examination. 

B. — Physical Properties. 
I. Quantity. 

The quantity of urine voided by a healthy man, 
eating and drinking in moderation, during twenty- 
four hours, varies from 1400-1600 c. c; average. 1500 
c. c. 

The greatest quantity is secreted during the after- 
noon; the smallest, during the night; the mean occurs 
in the morning, and, at this time, the urine represents 
in every respect, an average, being least influenced by 
meals. 

By means of the introduction of fluid into the sys- 
tem, the quantity of urine can be enormously increased 
(urina potus) : an increase, less marked, can be noticed 
during very cold or moist weather (less perspiration). 
During rest or profuse sweating, and copious diarrhoea, 
the quantity is diminished. 

II. Specific Gravity. 

The Specific Gravity of normal urine of 1.500 c. c. 
quantity is from 1.015 to 1.021. If the quantity in- 
creases or diminishes the specific gravity changes in 
inverse ratio. In pathological cases the specific gravity 
varies from 1.003 to 1.040. Those cases are of special 



24 EXAMINATION OF THE URINE. 

importance, in which, with small volume, there is low 
specific gravity, or with great volume high specific 
gravity. A high specific gravity is found frequently 
in diabetes mellitus, in the beginning of acute diseases 
and during the administration of salts. Urine great 
in quantity, having a specific gravity of between 1.003 
and 1.040 is always very suspicious as indicating 
diabetes mellitus. A low specific gravity is observed 
in hydruria, urina spastica and urina potus. 

Specific gravity can be accurately determined, either 
by means of the picnometer or the scales of AVestphal. 
For practical purposes, however, small areometers 
(called urinometers) are employed. 

When specific gravity is to be determined by means 
of the urinometer, a suitable vessel is filled four-fifths 
full, all air-bubbles are removed with filtering-paper? 
and the urinometer then introduced in such a way, it 
is allowed to slide between the index and middle 
finger of the right hand. The urinometer must not 
be allowed to touch the walls of the vessel. Bring the 
eye on the same plane with the surface of the fluid, 
and read from that division of the scale which corre- 
sponds with the surface of the urine (not with that 
surface which is drawn up on the scale by means of 
attraction). 

[Note. — A simple rule is to read from the lowest level of 
the fluid ; in this way both attraction of the walls of the ves- 
sel, and also of the stem of the urinometer, are disregarded.] 

Then the urinometer is immersed into the fluid and 
again read. 



PHYSICAL PROPERTIES. 25 

In taking specific gravity with the urinometer, the 
temperature must be between 12-17° c, otherwise a 
great error may arise. 

If the quantity of urine for observation be very 
small, it is to be diluted with two, three or four times 
its volume of water, the urinometer is then introduced, 
and the result is multiplied by the diluted volumes. 
Thus, if one volume of urine has been diluted with 
three volumes of water, and the areometer marks 1.008? 
the real specific gravity is obtained from this apparent 
specific gravity by multiplying the last two figures of 
1.008 by 1 + 3 = 4: 

1.008X4=1.032. 

The same quantity of solids which was dissolved in 
one volume before, is now dissolved in four; the 
specific gravity, after dilution, is, therefore, only one- 
fourth of the real, or the real specific gravity is four 
times that of the dilute. 

III. Solids. 

The quantity of solids excreted by the urine in 
twenty-four hours varies from 60 to 70 grammes. If a 
greater amount than 200.00 gr. is found, we are deal- 
ing with diabetes. If, on the other hand, the quan- 
tity being nearly normal, we find 21.00 grammes only, 
we have hydruria. In order to determine, approxi- 
mately, the quantity of solids present in twenty-four 
hours, either Trapp's (2) or Haeser's (2.23) co-efficient 
may be employed. (For accurate determination, see 



26 EXAMINATION OF THE URINE. 

Chapter V.) First, the specific gravity of the urine is 
found. The last two figures of this are multiplied by 
the co-efficient, and the product is the quantity of 
solid constituents found in 1000 c. c. (in grammes). 
The quantity of urine being known, it is easy to deter- 
mine how much is found in twenty-four hours. For 
instance, given a urine of 1500 c. c. in quantity during 
twenty-four hours, its specific gravity 1.020; in order 
to find the amount of solids in 1000 c. c, the last two 
figures (20) are multiplied by Haeser's co-efficient, 

2.33 : 

20X2.33=46.60. 

This product represents the amount of solids, in 
grammes, in 1000 c. c. of urine; from this the propor- 
tion : 

1,000 : 1500 : : 46.60 : x, 

is readily established, and its solution, x = 69.90 is 
the quantity in twenty-four hours ; nearly the normal 
quantity. 

In the following, the quantity of solids in twenty- 
four hours in various specimens of urine will be 

given : 

Ex. I. — Quantity, 4,000, c. c. 

Sp. gr. 1.007. 

07X2.33 = 16.31. 

1,000 c. c. urine, therefore, contain 16.31 grains solids— 4,000 

c. c. = 65.24 gr. From this we see that the quantity of solids 

' is normal, that the water alone is increased. 

Ex. II.— Quantity, 6,000 c. c. 
Sp. gr. 1.013. 
13.X 2.33 = 30.29. 



PHYSICAL PROPERTIES. 27 

In 1,000 c. c. urine we have 30.29 gr. solids in (>,000 c. c. 
1,000 : (5.000 : : 30.29 : x 
a:=181.74gr. 

In this urine the solids in twenty-four hours are more than 
double the normal quantity, showing a case corresponding in 
this respect to that of diabetes. 

Ex. III.— Quantity, 2,000 c. c. 
Sp. gr. 1.005. 
05X2.33=11.65 gr. 

1,000 c. c. contain 11.65 — 2,000=23.30 gr. The solid con- 
stituents are very much diminished — an hydruria. 

The differential diagnosis between diabetes insip- 
idus and hydruria on 'the one hand, and urina potus 
on the other, and also between oliguria and normal 
urine, can be made simply by taking the solid con- 
stituents of the twenty-four hours into consideration. 

Other important deductions can also be drawn from 
the quantity of solids and the specific gravity, the 
observer being led to these- by each individual case. 
Thus, where a disease of the kidney is proven, the 
quantity of urine being normal or diminished, and 
the specific gravity being very low, the deduction can 
be drawn that as urea represents nearly one-half the 
solids, this substance is not excreted in sufficient 
quantity, and uraemia may be imminent, etc. 

On account of the fact that the relations of the dis- 
solved fluids to each other is not a fixed one, computa- 
tion from specific gravity cannot be accurate. An ' 
error of 6% can be made (in abnormal urine even 
more), i. e. having computed in 1,000 parts 50 gr. of 
solids, and finding only 47 or 53 gr. on the next day, 



28 EXAMINATION OF THE URINE. 

we cannot say that the solids have increased or 
diminished. 

In judging the changes in the body by the specific 
gravity, we must, in addition, take into consideration 
whether or not the usual amount of food is taken up, 
or (as in acute diseases) whether the patient abstains 
from food. In the latter instance, an average of 30.00 
gr. must be taken, so that the patient passing 40.00 gr., 
having pneumonia and abstaining from food, really 
passes more than the normal quantity — an increase 
that takes place at the cost of the body. 

IV. Consistency. 

The consistency of normal urine is that of a thin 
fluid, easily to be separated into drops. Under patho- 
logical conditions it sometimes becomes thick. When 
a great amount of pus is present in alkaline urine, the 
urine can be drawn out like the contents of a cyst 
containing paralbumin : diluted with water and pre- 
cipitated with acetic acid, a dense cloudiness arises, 
which is an alkali albuminate, formed by the action 
of the alkaline urine on pus. 

In Isle de France, it is stated that urine is seen 
which coagulates in the vessel like lymph, and con- 
tains fibrin (fibrinuria). In our zone this form of 
urine is exceedingly rare. In several cases of papillary 
tumors of the bladder we have observed temporary 
fibrinuria. 

Urine, fluid at the time it was voided, reddish- 
yellow and containing very little blood, a few minutes 



PHYSICAL PROPERTIES. 29 

afterwards was changed to a trembling, gelatinous 
mass, which could no longer be poured from the vessel 
containing it. 

Upon shaking normal urine, foam is formed which 
disappears in a very short time when the vessel is put 
down: if the urine contains sugar or albumin the 
foam will remain for some time. (Bile also gives to 
urine a certain amount of tenacity, so that bubbles 
are retained upon the surface for some time.) 

V. Color. 

The normal color of urine of 1.020 sp. gr. and 1.500 
c. c. quantity in twenty-four hours is wine-yellow. 
In concentrated urine it varies from dark wine-yellow 
to that of amber: in diluted, from pale wine-yellow to 
straw-colored. The urine passed in the morning, or 
when people have perspired, always has a dark color, 
but in urina potus it is light. In addition, in patho- 
logical conditions, the urine undergoes much greater 
changes, for which, very commonly, abnormal coloring 
matter must be looked upon as the cause. 

Urine can be divided into the following varieties, in 
respect to color: 

1. Nearly Colorless. — In neuroses, especially, do we 
meet with a "urina spastica." which can hardly be 
distinguished from water. In other varieties of hy- 
druria and in diabetes the coloring may be very faint. 
although yellow is unmistakable. A change, however, 
can set in in the course of a few hours, so that then 
darker urine is passed. 



30 EXAMINATION OF THE URINE. 

Light urine arises from the presence of the normal 
quantity of coloring matter in much water (urina 
potus, urina spastica) or normal amount of water and 
diminished coloring matter (as in the granular kid- 
ney) ; in most cases both factors are present. 

2. Highly Colored. — Dark yellow, somewhat reddish r 
to red. This color is not only produced by concentra- 
tion, but frequently by the presence of uroerythrin. 
It is met with in febrile conditions, in the stages of 
increase and acme. 

3. Blood Red to Garnet is always produced by the 
presence of some foreign coloring matter. Numerous 
substances from the vegetable kingdom, when excreted 
by the kidneys impart to alkaline urine a red color- 
The same occurs when blood is found in the urine. 

4. Dark Brown to Black is caused by the presence of 
methsemoglobin in diseases of the kidney, especially 
hemorrhages; by the presence of biliary coloring mat" 
ter in the urine (icteric urine-jaundice) and by color- 
ing matter not definitely known; as in long continued 
attacks of intermittent fever. 

Sometimes in melanotic cancers, after the urine has. 
been allowed to stand for a long time, it becomes 
black. As this form of coloring matter has been 
found without the presence of a cancer, and vice versa, 
not much symptomatic reliance can be placed upon 
its presence or absence. After the external use of 
carbolic acid (for example, when Lister's method is 
employed) very dark urine is also observed, but this 
is not constant. 

Occasionally in the urine of children, a brownish 






PHYSICAL PROPERTIES. 31 

discoloration going from the surface to the bottom is 
observed, due to the presence of pyrocatechin. In 
lepra, as the fatal end approaches, we see the dark red 
urine changed to a dark brown (urorubrohematin). 

5. Green, of a dirty shade, is produced in jaundice 
by the presence* of biliverdin, and is of the same im- 
portance as brown icteric urine. 

6. Bluish, producing a dark blue film and a similar 
precipitate of indican. This urine is always alkaline 
— most frequently met with in cholera and typhus. 

VI. Transparency and Fluorescence. 

Normal urine is always clear and transparent, and 
only after it has stood a long time can we distinguish 
a small cloudiness of mucus (nubecula). With the 
microscope this is found to contain round and flat 
epithelial cells. 

The nubecula is usually more abundant in females, 
and more epithelium is found in it, especially in 
layers, coming from the genitals. 

Pathologically the urine becomes cloudy from all 
the substances that are found in the sediment. To 
detect the chemical nature of the turbidity, the follow- 
ing method is employed: A test-tube is filled one- 
third full of the urine to be examined, and carefully 
heated over the lamp. 

(a) If the cloudiness disappears entirely, urates 
which are beginning to be precipitated are suspended. 

(6) If the cloudiness does not disappear, but rather 
seems to increase, it may depend on carbonate of cal- 



32 EXAMINATION OF THE URINE. 



cium, the earthy phosphates or albuminous cellular 
elements (pus, blood). For differentiation a few drops 
of acetic acid are added. 

If the urine clears up, the earthy phosphates have 
caused the turbidity; if not, or if the turbidity in- 
creases, suspended pus or blood can in most cases be 
considered as the cause. Albumin also causes the 
latter reaction. 

(c) If the urine does not undergo any change when 
heated, and a slight increase in cloudiness, only, be 
detected, an abnormally great amount of mucus and 
bacteria can be deduced. 

There is sometimes a marked fluorescence in normal 
urine; as yet we are unable to state the substances 
that produce it. 

Alkaline urine appears greenish by reflected light; 
by transmitted light, yellowish red. Some urine 
shows the spectrum of urobilin. 

VII. Odor. 

The odor of fresh human urine is faintly aromatic. 
The substances causing this are unknown. If the 
urine has undergone alkaline fermentation, a distinct 
.ammoniacal odor is perceptible. In destructive pro- 
cesses in the bladder, a peculiar, fetid, sometimes fecal 
smell is present. Upon the introduction of certain 
articles of food, or the taking of certain drugs, the 
odor of the urine is changed in a marked manner; for 
instance, after eating asparagus, cauliflower, etc. After 






PHYSICAL PROPERTIES. 66 

turpentine, the odor is like that of violets. The odor- 
iferous principles of cubebs, saffron, etc., can also be 
detected in the urine. 

VIII. Reaction. 

Normal urine has an acid reaction; this depends 
principally on the acid phosphate of the alkalies. It 
may depend, also, upon free organic acids (lactic?). 
At all events, the role played by these acids in pro- 
ducing the reaction is secondary. 

If to a fluid containing free acid, a solution of 
sodium hyposulphite be added, it becomes turbid on 
account of the precipitation of sulphur. If this ex- 
periment be tried with urine, even after it has stood 
twenty-four hours, a very slight turbidity sets in, or 
sometimes, none at all; therefore (even if we do not 
consider this test as absolute), the amount of free acid 
in the urine cannot be very great. 

After a meal, alkaline urine is sometimes voided; 
this, however, disappears in a short time, and is of no 
clinical importance. 

Great acidity of the urine is important to the physi- 
cian, in that it may favor the development of sedi- 
ments or concretions, and may give rise to irritation 
of the kidneys and urinary passages (Vogel). 

Acid reaction may be changed to neutral or even 
alkaline. The internal administration of carbonates 
of the alkalies and earths, or organic salts (acetates, 
pomates, tartrates), w r hich change to carbonates in the 
organism, may cause the urine to become alkaline. 
e. v.— 4. 



34 EXAMINATION OF THE URINE. 

The urine may also be alkaline from ammonium- 
carbonate, being formed by urea having taken up 
water. At first, the quantity of ammonium-carbonate 
is only sufficient to neutralize the urine; neutral re- 
action would, therefore, possess the same importance 
as alkaline. 

Urine of strong alkaline reaction always justifies 
the conclusion that the bladder is diseased, provided 
excretion of carbonates of the alkalies has been ex- 
cluded. The test usually employed is very delicate 
bluish violet, and faintly red litmus paper. 

We must discriminate between the change to alka- 
line taking place before or after the urine has left the 
bladder. Furthermore, whether the alkalinity depends 
upon ammonium-carbonate (splitting up of urea), or 
fixed carbonate (absorption). This can be done by 
allowing the litmus paper to lie in a warm place until 
it becomes dry; if ammonium has produced the 
change, the red color reappears ; if this does not take 
place, the alkalies present are fixed. 

Occasionally urine is observed that turns blue lit- 
mus red, and red, blue. This reaction is known as 
the amphoteric, has found no explanation, and has no 
symptomatic importance. 

CHEMICAL COMPOSITION. 

(a) NORMAL ORGANIC CONSTITUENTS. 

We preface the discussion of the individual sub- 
stances by a table representing the average quantity 
excreted. In twenty-four hours there are voided: 



CHEMICAL COMPOSITION. 35 

Grammes. Per cent. 

JSolids 60—70 4.3 —4.6 

Urea 30—40 2.5 —3.2 

Uric Acid 0.4 — 0.8 0.03 —0.05 

Creatinin 0.5 — 1.0 0.036—0.062 

Hippuric Acid 0.3 — 1.0 0.02 —0.06 

Chlorides 10—13 0.7 —0.8 

Earthy Phosphates 0.9 — 1.3 0.07 —0.08 

Phosphoric Acid 2.5 — 3.5 0.19 —0.22 

Sulphuric Acid 1.5 — 2.25 0.16 —0.17 

From this we see that the greatest amounts are 
represented by urea and the cholrides. It is easily 
understood, also, how the absence or insufficient pres- 
ence of one of these substances would produce a 
marked effect upon the specific gravity. This does 
not hold good, to the same extent, for the other normal 
constituents, as they are excreted in relatively very 
small quantities. 

The amount of gases is practically unimportant. 
Carbonic acid gas is present in greatest amount (60 — 
150 c. c. in 1000 c. c. urine). Nitrogen is present in 
very small amount, and of oxygen, traces only can 
be found. 

I. Urea. 

Urea CH 4 N 2 is the most constant constituent, and 
the one that occurs in greatest amount. In twenty- 
four hours a healthy adult will excrete between thirty 
and forty grammes of urea. Animal diet produces 
a greater quantity of urea than mixed, and the latter, 
more than vegetable food, exclusively. In inanition 
the quantity falls to twenty, and even fifteen grammes. 



36 EXAMINATION OF THE URINE. 

The latter figures must be taken into consideration, if 
we wish to form an idea of the changes in the econ- 
omy of patients put upon absolute diet. 

The simplest way of obtaining urea from urine is as follows : 
After precipitating the inorganic salts with the barium solu- 
tion used in the volumetric urea test, evaporate to dryness, 
extract with alcohol, filter, then evaporate the alcohol ; finally 
recrystallize with absolute alcohol. 

Another method consists in concentrating urine to the con- 
sistency of a thin syrup, then adding pure nitric acid (cold) ; 
as a result, urea nitrate will be precipitated. These crystals 
are decomposed with barium carbonate, and after drying, the 
urea can be extracted by alcohol. 

Synthetically, urea can be made from ammonium cyanate ; 
80 parts of potassium ferro-cyanide are melted in a crucible 
with 30 parts of potassium carbonate. By means of 150 parts 
of litharge, the potassium cyanide which has been formed 
(CNK) is changed to the cyanate CNOK. This is then poured 
upon an iron plate ; when cool it is dissolved in a solution of 
80 parts of ammonium sulphate ((NH 4 ) 2 S0 4 ) in 500 parts of 
water; a double decomposition takes place, producing CN 
0,H 4 N (ammonium cyanate) and K 2 S0 4 (potassium sulphate). 
Filter and dry. During evaporation, the transposition of 
atoms takes place, so that from ammonium cyanate we obtain 
urea, as follows : 

u nh 4 ~~ tu ra 2 

(Ammonium cyanate.) (Urea.) 

The dried mass is extracted with alcohol, and allowed to 
crystallize. 

When examined through the microscope, the crys- 
tals formed by urea are seen to be glistening white 
needles; when viewed by the naked eye they seem 
to be long, transparent, quadrilateral prisms, whose 



CHEMICAL COMPOSITION. 



37 




ends are terminated by one or two slanting planes. It 
is easily soluble in 
water and alcohol, 
but insoluble in 
ether. Heated 
moderately on 
platinum, it melts 
and develops am- 
monia. Mixed 
with putrescent 
urine, or the secre- 
tion from cystitis, 
it is separated in 
the opposite direc- 
tion from its form- 
ation. It Splits a, crystals of urea ; b, crystals of nitrate of urea. 

into 1 molecule of carbonic acid gas, and two mole- 
cules of ammonium, taking up 1 molecule of water 
(CH 4 N 2 0+H 2 0=C0 2 +2H 3 N). 

This same decomposition takes place when boiled 
with strong mineral acids, melted with caustic alka- 
lies, or when heated with barium hydrate in a sealed 
tube. When nitrous acid, sodium hypochlorite or 
hypobromite are added, urea is split up into carbonic 
acid, water and nitrogen. 

Urea is carbamide. For details see K. B. Hof man's Zoo- 
chemistry — in English — Fowne's Elementary, or Kingzett's 
Animal Chemistry. 

Mercuric nitrate with solutions of urea produces a 
flaky white precipitate, equaling 2, 3, or 4 equivalents 
of mercury to 1 of urea, depending on the concentra- 



38 EXAMINATION OF THE URINE. 

tion of the fluid. Urea also enters into combination 
with common salt. 

When nitric acid is added to concentrated urine, or 
to a concentrated solution of urea, beautiful rhombic 
plates are formed, which may frequently be seen with 
the naked eye. 

If one has only a drop of fluid which must be 
tested for urea, this is put upon a slide, and a drop of 
nitric acid is added ; this is gently heated over a spirit 
lamp, then put aside to crystallize. Under the micro- 
scope there are observed, either single rhombic or hex- 
agonal plates, or these are seen in great number, more 
or less developed, lying upon each other like shingles, 
and in rows, generally intersecting each other at right 
angles. The acute angle of the rhombus is 82 degrees. 
This test is most frequently resorted to on account of 
the facility with which it is carried out, and also on 
account of the characteristic form of the crystal of 
nitrate of urea. 

In albuminuria the nitrate of urea takes another 
form, that of brush-shape needles. (Hoffman, 1. c.) 

A concentrated solution of urea, decomposed by ox- 
alic acid, produces crystals that look like those of 
nitrate of urea; but as this form does not appear so 
regularly as the former, this reaction is looked upon 
more as one corroborating and verifying, having been 
preceded by the nitric acid test. 

These reactions can all be carried out with concen- 
trated urine, but when albumin is present, this must 
first be gotten rid of by means of coagulation. 

If the question comes up whether a fluid is urine, 



CHEMICAL COMPOSITION. 39 

the first thing to be decided upon would be the deter- 
mination of the presence of urea and uric acid. If a 
few drops only were presented, the micro-chemical 
reaction for urea would be decisive. We must not 
forget, however, that some transudations contain 
urea. 

As urea, of all the constituents of urine, is present 
in greatest quantity, we can deduct from the specific 
gravity the approximate quantity of urea, provided 
no sugar and no great amount of albumin can be de- 
tected, and provided the chlorides be present in nor- 
mal quantity. This being the case, and having a 
urine whose specific gravity is between 1020 and 1024, 
we can state that such an urine contains a normal 
percentage of urea, i. e., between 2 and 2.5%. If, 
under the same conditions, we find increased or 
diminished specific gravity, we can state that the per- 
centage of urea is correspondingly increased or dimin- 
ished. If the specific gravity is 1014 the urine con- 
tains about 1% of urea; if 1028—1030, it contains 3% 
of urea. 

If the chlorides are present only in small quantity, 
or can not be detected at all, as occasionally happens 
in acute febrile diseases, even with normal specific 
gravity, then the percentage of urea is increased. For 
the 16 grammes of chlorides that are present in nor- 
mal urine, and which form the second greatest factor 
in influencing specific gravity (always excluding sugar 
and albumin), are absent in this case, therefore the 
specific gravity of 1020 must be produced by the urea; 
for all the remaining constituents of urine, uric acid. 



40 EXAMINATION OF THE URINE. 

creatinin, the phosphates and sulphates, even if their 
normal quantity be doubled, could have very little 
influence upon the specific gravity. 

If albumin is present in moderate quantity (0.2%) 
it has very little influence upon specific gravity, and 
can be neglected entirely in the approximation of 
urea; this can be ascertained by means of the nitric 
acid test, which, in this case, would produce a trans- 
lucent layer of precipitate. But if albumin be present 
in greater quantity (1 — 2%) it must be removed by 
coagulation, and the filtered urine must be examined 
after it has cooled off. 

For this purpose it is best to take a given quantity 
of urine, for instance, 50 c. c. ; after adding a few drops 
of acetic acid, heat in a flask to the boiling point ; 
allow it to cool, then filter, and wash the filter paper 
with distilled water until the fluid lost by evapora- 
tion is made up. Thereupon the specific gravity of 
this urine that has been deprived of albumin, is deter- 
mined. 

Urine containing albumin is usually in and of 
itself, of a lighter specific gravity than the normal 
urine. The diseased urine-producing organs can not 
secrete urine containing the normal quantity of ex- 
cretory material (especially urea). As a result, the 
specific gravity must become less. The quantity of 
albumin is rarely sufficiently great to substitute the 
urea in regard to specific gravity. 

When sugar is present in large quantity the per 
cent, of urea is always diminished, although the 



CHEMICAL COMPOSITION. 41 

entire quantity of urea excreted is always increased. 
The high specific gravity depends upon the sugar. 

Notwithstanding many statements to the contrary, 
we have never succeeded in obtaining urea artificially 
from protein. Still, this must be considered as its 
only source. 

Urea is not the only measure of tissue change, but 
it is the most important one. It owes its origin, partly 
to the retrograde metamorphosis of tissue (including 
blood), and partly to the decomposition of superfluous 
nitrogenous food. Whether it originates in gradual 
oxidation ; whether its molecule is separated from one 
more complex, by means of fermentation; whether 
this separation takes place from the albumin-molecule 
directly, or from a gradual division of this molecule 
into smaller ones (intermediate molecules), from 
which, by oxidation, urea is generated, is, as yet, un- 
decided. It is proven that certain combinations that 
are found in the body, belonging to the uric acid 
group (uric acid, allantoin, creatin, sarcin, xan- 
thin, guanin,) and certain derivates of protein (gly- 
cocoll, leucin, aspartic acid,) when introduced in 
considerable quantities into the body will produce an 
increase in urea. 

An increase of the urea, to such an extent that 
upon the addition of nitric acid a pulp of nitrate of 
urea is formed is found : 

1. When the diet is principally animal. 

2. In acute febrile diseases, until the acme is 
reached. Urea in this case comes from increased wear 
of the nitrogenous elements. 



42 EXAMINATION OF THE URINE. 

3. In diabetes mellitus and insipidus. 
Urea is diminished : 

1. When the diet is vegetable, and in fasting. 

2. In chronic diseases where tissue change is im- 
paired (cachexias). 

3. In parenchymatous affections of the kidney, 
accompanied by uraemia, especially before death 
(7gr.!). 

The percentage of urea is diminished in urina 
potus, spastica and diabetes, but if the quantity in 
twenty-four hours be taken into consideration, it will 
be found that the urea is usually increased ; it is pres- 
ent in normal quantity at least. 

II. Uric Acid. 
C 5 NH 4 3 . 

Uric acid is always found in the urine of carnivora. 
The healthy adult usually voids from 0.4 — 0.8 
grammes in twenty-four hours. 

It is sparingly soluble in (14,000 parts of cold and 
1,800 of warm) water, and entirely insoluble in alco- 
hol and ether. This alone speaks for the fact, that 
uric acid is not present free in the urine, but nearly 
all of it in the form of the urates. 

In a warm solution of normal alkali phosphate, 
uric acid is much more soluble than in water, because 
it withdraws from the phosphate part of its base. In 
this way, then, is produced an acid alkali phosphate 
and an alkali urate. 

Free uric acid, as well as its salts, always appears 






URIC ACID. 43 

colored in the sediment, the intensity depending on 
the color of the urine. 

In order to obtain nric acid from urine, 20 parts of the 
latter are mixed with one part of hydrochloric acid, and the 
whole allowed to stand for twenty-four hours. A crystalline 
powder or membrane is separated, consisting of uric acid, on 
the bottom and walls of the vessel, and also on the surface of 
the fluid. 

The primary crystal of uric acid is the whetstone, 
or, better, a rhombic vertical prism. In this form, and 
its variations we find it also in native sediments. If 
uric acid is separated from urine by means of hydro- 
chloric acid, the forms are somewhat changed. They 
seem coarser and more highly colored. Usually there 
are found under the microscope double whetstones, in 
the form of a cross; groups of narrow and long whet- 
stones arranged parallel to each other, or like needles, 
which somewhat resemble a comb, having teeth on 
both sides. It is rare to find single crystals. If the 
uric acid w T hich has been precipitated by hydrochloric 
acid, is separated by filtration, redissolved in potas- 
sium or sodium hydrate, and reprecipitated by hydro- 
chloric acid, the result will be a much whiter deposit. 
Repeating the process, frequently, will finally produce 
snowy white crystals, even from human urine. Uric 
acid can also be purified by means of dissolving in 
sulphuric acid and then precipitating by adding a 
great quantity of water. 

Uric acid or the urates should never be present in 
fresh urine; w r hen they are, our attention must be 
drawn to the formation of calculi. In the formation 



44 EXAMINATION OF THE URINE. 

of gravel and calculi, concrements of uric acid, which 
are too large for microscopic examination, are passed, 
and which do not, therefore, permit of an accurate 
diagnosis regarding their structure. In these cases 
the chemical test, murexid, will give us positive re- 
sults. 

To make this test, the concrement is pulverized in 
a small mortar, put into a porcelain evaporating dish, 
and a few drops of nitric acid and a small quantity of 
water added. These are heated until the uric acid is 
dissolved, and the fluids driven off. During evapora- 
tion, if uric acid is present, we notice intense red 
deposits on the walls of the vessel, which disappear 
when the temperature is sufficiently raised by approx- 
imating the lamp to the vessel. When the solution 
has been evaporated nearly to dryness, upon the addi- 
tion of a drop of aqua ammonia, the whole contents 
of the dish appear of a beautiful purple (murexid- 
purpurate of ammonium) ; when a drop of a solution 
of potassium hydrate is added to this, the solution 
appears violet. This reaction depends upon a change 
in the uric acid to alloxan and alloxantin, which are 
converted into murexid by the ammonium. 

Instead of using the test, the concrement may be 
dissolved in potassium hydrate, precipitated by hydro- 
chloric acid and examined under the microscope, the 
crystals being characteristic for uric acid. 

If only a small quantity of fluid is at our disposal, 
and we wish to test for uric acid, it should be put into 
a watch glass together with a linen thread; add 6 — 8 
drops of glacial acid, and allow the whole to stand for 



URIC ACID. 45 

twenty- four hours at 15° C, then examine with the 
microscope to see if crystals of uric acid are deposited 
upon the thread. 

If to an alkaline solution of uric acid, a weak solu- 
tion of copper sulphate be added, a white precipitate 
of cuprous urate will be formed. If an excess of 
cupric oxide be added and the whole boiled, the red 
cuprous oxide will be precipitated ; for oxygen of the 
cupric oxide is used for the oxidation of the uric acid. 
We therefore find in the solution, urea, allantoin and 
oxalic acid. This alkaline solution of uric acid will 
also reduce nitrate of silver. If the two are mixed in 
small quantities, a spot will be found upon the filter, 
black if there is present 1-1000 uric acid, or brownish- 
yellow if there is 1-500,000. 

By means of ozone, in the presence of an alkali, 
uric acid is converted into urea, ammonia, oxalic acid 
and carbonic acid; when the alkali is absent, into 
urea, carbonic acid and allantoin. 

When acted upon by various oxidizing agents, uric 
acid gives rise to a great number of interesting prod- 
ucts, most of which can be considered urea in which 
atoms of hydrogen have been displaced by acid-radi- 
cals. It seems that uric acid itself contains the rem- 
nants of two molecules of urea. 

Uric acid is a bibasic acid, and as a result, two series 
of salts are formed, neutral and acid. 

The neutral salts are more readily soluble in water 
than the acid salts. Acid sodium-urate requires 124 
parts of boiling, and 1150 parts of cold water to dis- 
solve it. Therefore, if we find urates in the sediment, 



46 EXAMINATION OF THE URINE. 

we know that they are acid salts. On the other hand, 
if we find urates in solution, especially after the urine 
has acquired the temperature of the room, we can as- 
sume that they are, principally, neutral. This view 
is supported by the fact that if an urine correspond- 
ing to the preceding is decomposed by a strong acid 
(muriatic or nitric), the whole urine at first becomes 
cloudy. If this cloudiness is examined under the 
microscope, we see that it is produced by amorphous 
points, which are acid urate of sodium. After having 
stood for some time, the milky cloudiness disappears, 
and in its stead appears a distinct crystalline deposit 
of free uric acid. This phenomenon can only be ex- 
plained by assuming that in the clear urine neutral 
urates were held in solution, from which, by the addi- 
tion of acids, some of the base was taken, producing 
the less soluble acid urates. The acid continuing to 
act, all the base is taken from the urate, leaving free 
uric acid. 

In the reaction for albumin, when the nitric acid is 
poured under the urine, it is an established fact that 
frequently a layer is produced which, by the inexperi- 
enced, might be taken for the albumin precipitate. 
This, however, consists simply of amorphous acid 
urates, which are changed to uric acid on standing. 

The acid urates of sodium and ammonium will find 
consideration under the heading of sediments. The 
causes for the increase or diminution of uric acid 
have not, as yet, found a satisfactory explanation. 

Uric acid is considered as a preliminary step toward 
the formation of urea, although it is not at all prob- 



URIC ACID. 47 

able that all the urea of the body is developed in this 
manner. From this the increase of uric acid was ex- 
plained in all those conditions in which oxidation of 
the nitrogenous excretions is insufficient, either from 
the presence of too little oxygen or from the increased 
formation of uric acid, which is too great for the nor- 
mal quantity of oxygen to dispose of. Many facts, 
however, do not harmonize with this explanation. 

Uric acid, as derivative of protein compounds, has 
the same importance for the economy as urea. 
Usually, therefore, we find an increase of uric acid, 
where urea is excreted in greater quantity. 

We find an increase of uric acid : 

1. Where a great quantity of food is taken, either 
animal or vegetable diet, with little exercise in the 
open air. 

2. In acute febrile diseases, where many nitro- 
genous compounds are decomposed. 

3. In diseases of the lungs and heart, accompanied 
by insufficiency of respiration. 

4. In all those cases in w T hich the diaphragm is 
prevented from performing its function; in large 
tumors of the abdomen, ascites, etc. 

5. In leucaemia, either on account of increased 
production of uric acid by the diseased spleen, or on 
account of diminished oxidation by the blood, poor 
in red corpuscles. 

6. In the so-called uric acid diathesis. 

A diminution is usually found in chronic diseases 
of the kidney, diabetes mellitus (occasionally), urina 
spastica, hydruria and arthritis. 



48 EXAMINATION OF THE URINE. 

To determine, approximately, the quantity of uric 
acid in urine, the following may be used: Normal 
urine of 1020-1024 sp. gr. neither precipitates uric 
acid nor urates at the ordinary temperature, nor can 
we detect a precipitate upon using the nitric acid test. 
If concentration increases, there will be observed in 
the sediment a small quantity of free uric acid, and 
the nitric acid test will reveal a narrow layer. In 
such cases, however, the specific gravity is always in- 
creased; therefore, urea, and with it, uric acid, are 
present in greater quantity. If the quantity is nor- 
mal, and we find much brick-dust sediment, and also 
urates in solution, or a considerable sediment of uric 
acid, the uric acid is increased. 

But if the quantity is diminished, this conclusion 
can not be drawn. In this case, although the urates 
are present in normal quantity, there may not be 
sufficient fluid present to hold them dissolved at the 
ordinary temperature. 

For ordinary purposes it is safe to consider uric acid 
as diminished where urea is. All that has been stated 
refers to the quantity in percentage. If we wish tp 
have an idea concerning the whole quantity, we must 
naturally, take the quantity of urine passed in twenty- 
four hours into consideration. It is best to compare 
with normal urine. The average quantity is 1500 c. c. 
We must, therefore, add enough water to make up 
these 1500 c. c. in twenty-four hours. If we take the 
quantity in twenty-four hours as 1000 c. c, we must 
add 500 c. c, or, to 10 c. c. of urine 5 c. c. of water. 
Two test tubes of equal diameter are selected; into 



UROBILIN. 49 

one is put 15 c. c. of normal urine; into the other, 10 
c. c. of the concentrated urine, and to both are added 
10 drops of muriatic acid, and then allowed to stand 
for twenty-four hours. From the precipitate Ave can 
easily determine whether the uric acid is increased or 
diminished in the urine that is compared with the 
standard. If the quantity is greater than 1500 c. c, 
the corresponding dilution of the normal urine must 
be had recourse to, 

III. Coloring Matter! 

In normal urine there occurs urine indican and a 
pigment, urobilin. Besides these well known bodies, 
there are found several other pigments, which, how- 
ever, have not been thoroughly studied. 

(a) Urobilin. 

Urobilin is a brown, resinous mass, readily soluble 
in water, but more readily in alcohol, ether and 
chloroform. Concentrated solutions are brown, vary- 
ing from a yellow to a pink. They have no reaction 
with litmus, by reflected light show a beautiful green 
fluorescence, and with the spectroscope possess a dark 
band of absorption between the Frauenhofer lines b 
and F. The fluorescence and spectroscopic appearance 
become more distinct upon the addition of ammonia 
and a trace of chloride of calcium. Upon the addition 
of hydrochloric acid, however, the fluorescence dis- 
appears, and the absorption band approaches K, be- 
comes fainter and has less marked outlines. If am- 

E. U.— r,. 



50 EXAMINATION OF THE URINE. 

monia is added to the acid solution, its brown or red 
color is changed to a light yellow, approaching a green. 
Alkaline solutions show the same absorption band, 
and, at the same place as neutral solutions. 

In order to obtain urobilin, it is advisable to take dark fever 
urine. It is made strongly alkaline by ammonia, filtered, and 
then chloride of zinc is added until no precipitate is produced. 
The precipitate is washed upon the filter, first with cold, then 
with warm water, until nitrate of silver* no longer produces 
turbidity in the water used for washing. Then it is boiled 
with alcohol, dried at a moderate heat, the powder dissolved 
in ammonia and precipitated with lead acetate. The precipi- 
tate is then washed a little with water, decomposed with a 
moderate quantity of alcohol, containing sulphuric acid, and 
filtered. To the filtrate an equal quantity of chloroform is 
added, shaken, in order to remove the sulphuric acid, adding 
fresh water until this shows traces of color. Upon evaporating 
the chloroform, the urobilin remains in the form of a resinous 
mass. 

According to the researches of Maly, urobilin is a 
result of the reduction of bilirubin. As Hoppe-Seyler 
has succeeded in producing a compound identical with 
urobilin, by means of acting on blood-coloring matter 
with hydrochloric acid and tin, and as, on the one 
hand, the injection of substances that destroy the 
blood corpuscles increases the formation of biliary 
coloring matter, we can hardly doubt that urobilin is 
the direct or indirect result of the reduction of 
haemoglobin, and therefore its increase is of interest 
to the physician. It is found in acute febrile diseases, 
and points to an increased waste of red blood cor- 
puscles. 



URINE-INDICAN. 51 

Urine which, without any further preparation, 
shows a greenish fluorescence upon the addition of 
ammonia and chloride of zinc, and the characteristic 
absorption line, can be put down as rich in urobilin. 

Scherer's urohaematin, Heller's urophaein, Thudicum's 
urochrome, etc., are bodies for whose purity we have no 
guarantee ; indeed, for urochrome and urohaematin, Maly has 
shown that both contain much urobilin. 

(b) Urine-Indican. 

Since the time of Heller, it is known that an addi- 
tion of hydrochloric acid to urine will produce a 
peach-blossom red, violet, or deep blue discoloration. 
The red he attributed to urrhoclin, the blue to uro- 
glaucin, and the coloring matter from which both 
arise, and which he conceived to be yellow, he called 
uroxanthin. Uroglaucin was also found in sponta- 
neously putrid urine, and has been identified with the 
indigo of plants. Uroxanthin was therefore con- 
sidered the same as indican, the mother substance of 
indigo white found in plants. Recent investigations 
have shown that the body which forms the indigo 
found in urine is not identical with plant-indican. 
We will therefore call it urine-indican. 

This substance can be obtained pure by means of precipita- 
ting with lead acetate, decomposing with ammonia ; this pre- 
cipitate, suspended in alcohol, is subjected to a current of 
sulphuretted hydrogen gas, then filtered from the lead sul- 
phide, evaporated by gentle heat, finally in vacuo over sul- 
phuric acid. More complicated methods are known. For 
particulars, see Hoppe-Seyler, Chemische Analyse, p. 191. 



52 EXAMINATION OF THE URINE. 

Urine-indican is not a glucoside, because, upon 
splitting it up no sugar is found ; it is a bi-sulpho acid 
on account of the treatment with hydrochloric acid's 
giving large quantities of free sulphuric acid. In the 
uncombined condition, these acid-ethers are unstable, 
and putridity, as well as the action of mineral acids, 
decompose them. Simultaneous, in both instances, 
there is an oxidation, so that the formation of indigo 
does not depend solely upon a splitting up. The one 
product is indigo ; a second is a red body, whose sub- 
limate condenses to fine red needles, which may bei 
identical with Heller's urrhodin. Upon the quantity 
of these two products depends the color which is pro- 
duced upon the addition of hydrochloric acid to 
urine. 

When concentrated sulphuric acid is allowed to drop into 
urine from some height, the mixture is usually colored more 
or less dark red. This seems to depend upon various products 
(probably the splitting up of urine coloring matter). In the 
presence of sugar, albumin and constituents of the bile, un- 
doubtedly all participate in the splitting up, so that the mix- 
ture may become opaque and brownish black (Heller's uro- 
phgein test). As this mixture generates a considerable 
amount of heat, many substances, such as iodine, the odor- 
iferous oil of cubebs, of sassafras, etc., escape, and are detected 
by the smell. In parenchymatous purulent processes in the 
bladder, an exceedingly offensive and penetrating odor is 
generated. 

The oldest test for indican is the uroxanthin test of 
Heller. 

1. This is carried out in the following manner: 
There is poured into a beaker 3-4 c. c. of pure hydro- 



URINE-INDICAN. 53 

chloric acid, and into this are dropped from 10-20 
drops of urine, and the mixture is stirred with a glass 
rod. Under normal conditions, there is only sufficient 
indican present to give the mixture a light yellowish- 
red tint. If, however, the acid becomes violet or blue, 
then the quantity of indican is greater than normal. 
The more indican there is present, the more rapidly 
does this change take place, and sometimes 1 or 2 
drops of urine are sufficient to give a blue tint to 4 c. 
c. of hydrochloric acid. If, after 1 or 2 minutes, no 
violet is perceived, indican is not increased, even 
should the mixture turn dark reddish-brown after 
standing from 10-20 minutes. 

In the urine of jaundice, the biliary coloring matter 
must first be precipitated with acetate of lead, and 
the whole be filtered before performing the test. 

The color in the uroxanthin test is, unfortunately, of little 
value, as it not only represents the quantity, but also the 
varied capability of decomposition of indican; how incon- 
stant this is, is proven by the fact that urine-indican produces 
at one time more indigo # blue, and at another, more indigo 
red. Above all, it must be observed that albumin with hydro- 
chloric acid, especially when heated, or the action has gone 
on for some time, shows a violet color. Notwithstanding this, 
the dark blue color may be looked upon as a sign of increase 
in indican. 

2. 10 c. c. of urine are mixed w^ith equal quantities 
of hydrochloric acid, and then either a saturated solu- 
tion of calcium chloride, or simply chlorine water is 
dropped into the mixture, and the color is observed 
(Jaffe's test). 



54 EXAMINATION OF THE URINE. 

3. Heat about 5 c. c. of urine moderately, with 
double its quantity of nitric acid, then shake with 
chloroform, which will take up the indican, and ex- 
amine this chloroform extract with the spectroscope 
(Stokvis' test). 

If indol is introduced into the system, indican is 
very much increased; the same occurs if the small in- 
testine is ligated. The pancreas digestion produces, 
in its last stage, indol; by tying the intestine this is 
increased, absorbed and finally produces an increase 
in the urine-indican. The albumin of food, then, is 
a source of indican. In the ordinary putrefaction of 
albumin, indol is generated. On the other hand, it is 
becoming more probable that a part of the albumin 
in the body, as the result of a fermentative process, is 
divided up as it would be by putrefaction outside of 
the body. The albumin of the tissues, then, is the 
other source of indol, and therefore of indican. In 
this way may be explained how, in fasting, indican 
does not entirely disappear from the urine, being 
formed at the cost of the disintegrating tissues. 

Indican is increased ; in meat diet, in Addison's dis- 
ease, in cholera, in cancer of the liver; it is enor- 
mously increased in all diseases that produce a closure 
of the small intestine (incarceration, invagination, 
etc.) ; not so much in obstruction of the large intes- 
tine ; ordinary constipation. It is very much increased 
in cancer of the stomach and peritonitis. In disease 
of the kidney, with the exception of the granular 
kidney, indican is not much increased. In general, 
chronic consumptive and inanition-processes increase 



OTHER NORMAL ORGANIC CONSTITUENTS. 55 

it rather than acute diseases. Fever does not cause 
the same increase in indican that it does in urobilin. 

Increase of- urine-indicant in lesions of the central and peri- 
pheral nervous system has only been determined by means of 
the reaction for uroxanthin, and therefore awaits further, 
more accurate investigation to make this result positive. 

IV. Other Normal Organic Constituents. 

We will only give brief mention of the remaining 
organic constituents, as they possess, thus far, very 
little value for purposes of diagnosis. 

Kreatinin — the strongest base in the body — is passed in the 
same quantity as uric acid. The average quantity for twenty- 
four hours is between 0.6-1.3 grammes. In vegetable diet the 
quantity is smaller than in animal diet. It has been found 
increased in pneumonia, intermittens and typhus ; diminished 
in inanition and advanced disease of the kidney. 

Hippuric Acid is found principally in the urine of herbivora. 
In human urine it is found in very small quantities. The 
average quantity is between 0.5 and 1.0 grammes in twenty- 
four hours. After eating certain kinds of fruit (green gages, 
whortleberries, etc.), and after the administration of benzoic 
acid, hippuric acid is increased. This is also the case in 
febrile diseases and in diabetes ; it is diminished when exclu- 
sive meat diet is used. If the quantity is increased very 
much, hydrochloric acid will cause a precipitate of hippuric 
acid, just as it would of uric acid. 

Xanthin and the phenol-producing, disulphonic acid, are 
found in very small quantity in the urine. The former can 
only he obtained from several hundred liters of urine, in suffi- 
cient quantity for qualitative tests. The presence of phenol- 
forming substances is indicated by the phenyl reaction of the 
urine when it has previously been acidulated with a strong 



56 EXAMINATION OF THE URINE. 

i 
mineral acid. If, however, tartaric acid is used, the distillate 
of normal urine shows no phenol reaction, proving that 
phenol (carbolic acid) only exists in urine in a combined 
state. 

Mesoxalic Acid is found in very small quantity. It is the 
result of the indirect oxidation of uric acid, which produces 
parabanic acid ; this, taking up water, is converted into mes- 
oxalic acid, and, finally, when boiled with w T ater. into urea 
and oxalic acid. 

Oxalic Acid is found in the sediment in the form of its cal- 
cium salt. 

Concerning the presence of Sugar in normal, urine, authori- 
ties are divided. At all events, a substance is found in nor- 
mal urine which, in common with the urates, will reduce 
copper sulphate in alkaline solutions. 

In normal urine the existence of Lactic Acid has not been 
positively decided upon. In pathological urine, two kinds of 
lactic acid, occurring in fermenting urine of diabetes, and 
sarcolactic acid, after phosphorous poisoning, in acute yellow 
atrophy of the liver, in malacosteon and trichinosis. 

B. — Normal Inorganic Constituents. 

1. — Chlorides. 

In human urine we find the chlorides limited to 
the chloride of sodium, to the almost entire exclusion 
of chloride of potassium. The average quantity found 
in the urine of a healthy man for twenty-four hours, 
is from 10 to 16 grammes (6-10 gr. chlorine). After 
urea, chloride of sodium is the principal constituent 
of urine — indeed, in accordance with this fact, urine 
possesses a salty taste. If a drop of urine be evapo- 
rated on a slide, and put under the microscope, be- 






CHLORIDES. 57 

sides the rhombic plates of urea, chloride of sodium 
will be found in flat octohedra or incompletely de- 
veloped crystals of the tessular system. 

It is frequently important for the physician to find 
out easily and quickly whether or not the chlorides 
are increased. This can be done in the following 
manner : 

If a solution of common salt is decomposed by 
nitrate of silver, a white precipitate of chloride of 
silver is produced : 

NaCl+AgN0 3 =NaN0 3 +AgCl. 

But if we have a solution which also contains phos- 
phates, as urine, we must acidulate with a little nitric 
acid before making the test, so as to prevent the phos- 
phoric acid from precipitating with the silver, thus 
increasing the latter. An unimportant inaccuracy i& 
produced by simultaneous precipitation of uric acid ; 
this, however, can not be prevented. The nitric acid 
prevents the formation of phosphate of silver, but not 
of the insoluble chloride. If a solution of nitrate of 
silver of constant strength (1 in 8) is taken for this 
test, and single drops are added to \- 1% solution of 
common salt (as urine), they will fall to the bottom 
of the vessel in the form of cheesy masses, not to be 
subdivided by shaking, and never producing cloudi- 
ness. If we have- a very dilute solution, -^% and 
under, no masses are formed, but the entire fluid pre- 
sents a uniformly milky and turbid appearance. 

This method can be utilized for the examination of 
urine in the following way: Fill a wine glass half 



58 EXAMINATION OF THE URINE. 

full of urine which has been acidulated with nitric 
acid, and add one or two drops of the silver solution. 
If the drops come down as cheesy globules, the 
chlorides are not diminished ; if a milkiness is pro- 
duced they are very much diminished; if this is 
wanting, they are entirely absent. 

The test for albumin can be made to serve as a test for salt. 
Stir nitric acid with the urine, and then add the nitrate of 
silver. If much albumin is present, the coagulum must be 
removed by filtration before performing the test for the 
chlorides. 

The chlorides are diminished : 

1. In all acute febrile diseases, especially if com- 
bined with serous exudations or watery passages. The 
quantity of chlorides is in direct ratio to the quantity 
of urine, and in inverted ratio to the specific gravity 
and quantity of urea, until the acme of the febrile 
process is reached. 

As a rule, the kidney excretes only the excess of 
chlorides. In inflammatory processes, common salt 
frequently collects in the exudations (pleuritis). On 
the whole, in connection with acute processes, it may 
be said of the chlorides, that their increased diminu- 
tion indicates an increase of the disease, and vice 
versa. 

In pneumonia, for instance, the chlorides may be 
entirely absent without our being able to account for 
it by their diminished introduction into the system. 

In typhus or meningitis they are diminished, but 
not absent. Absence of chlorides always indicates a 
grave affection. 



PHOSPHATES. 59 

3. In chronic diseases, with diminished digestive 
powers, or dropsy. 

Increase of the chlorides is observed : 

1. When much salt is introduced. 

2. When much physical or mental labor is per- 
formed. 

3. During paroxysms of fever and either before or 
after. Throughout the twenty-four hours this is com- 
pensated for. so that the whole quantity is normal, or 
even sub-normal. 

4. In diabetes insipidus. 

5. In dropsy, as soon as diuresis has been estab- 
lished, so that the pent-up chlorides suddenly find 
escape. 

2.— Phosphates. 

The whole amount of phosphoric acid passed in 
twenty-four hours is between 2.3 and 3.8 grammes; in 
healthy men the average is 3.5 grammes. The diurnal 
variations can be very great. The quantity increases 
after the meal until evening (maximum), and falls 
during the night until next morning (minimum). 

We find an increase of phosphoric acid in urine : 

1. After the introduction of phosphorus, phos- 
phoric acid, or the soluble phosphates into the organ- 
ism. 

2. When the diet is principally animal, and es- 
pecially when food is taken that contains more or less 
prepared phosphoric acid as brain. 

3. In all acute febrile diseases (not always). 

A diminution is found in all urine of low specific 



60 EXAMINATION OF THE URINE. 

gravity: urina potus, urina spastica, etc., in kidney 
and in heart disease, with diminished urine; in serious 
disturbances of digestion, and in chronic brain troubles 
(except epilepsy). 

Phosphoric acid P0 4 H 3 is a tribasic acid, i. e., the 
three atoms of hydrogen can be displaced by metals. 

In urine this acid is partially bound by the earthy, 
partially by the alkaline bases (earthy and alkaline 
phosphates). 

(d) The earthy phosphates, i. e'., of calcium and 
magnesium are found, normally, in very small quan- 
tity (0.9-1.3 grammes in twenty-four hours). Mag- 
nesium phosphate is present in about double the 
quantity of calcium phosphate. In acid urine we 
find these salts in solution ; in alkaline urine, how- 
ever, they are found in the sediment. 

Phosphoric acid forms, with calcium, three salts : 

pojo} Ca 

The neutral : f } Ca " ( P0 4) 2 Ca 3 

™{g}c. 
rOH 

The single acid : PO j O J Ca +2H 2 0=P0 4 HCa+2H 2 

OH 
PO^OH 



The double acid : ^|Ca + H 2 = (P0 4 H 2 ) 2 Ca+H 2 

PCM OH 
(OH 

The last combination is found dissolved in urine. 
A double magnesium-phosphate is not known. The 



PHOSPHATES. 61 

single acid salt is said to be held in solution in urine 
by free acid (?). 

The reaction for the soluble earthy phosphates is 
performed by alkalies (sodium, potassium, or am- 
monium). 

In calcium phosphate, acid is withdrawn thus : 

3[(P0 4 H 2 ) 2 Ca]+12KOH=(P0 4 ) 2 Ca 3 +4P0 4 K 3 +12H 2 0. 

With magnesium-phosphate, on the other hand, 
ammonium-magnesium phosphate is formed if am- 
monium is used : 

p6 4 .HMg+NH 3 +6H 2 0=P0 4 Mg(NH 4 )+6H 2 0. 

The crystalline form will be described in connection 
with the sediments. 

In order to test for the earthy phosphates, fill a test- 
tube one-third full with clear urine, acid a few drops of 
caustic potassium or ammonia, and heat until the 
earthy phosphates precipitate in flakes; put the test- 
tube on a stand for 10-15 minutes, until the precipi- 
tate is deposited, and then judge of the quantity. If 
we hare used a test-tube about 16 c. long and 2 c. in 
diameter, a layer of 1 c. in depth will represent the 
normal quantity; if the layer is 2-3 c. deep, the earthy 
phosphates are increased ; if only a few flakes are pres- 
ent, they are diminished. 

In normal urine they form a white precipitate; if 
the urine contains abnormal coloring matter, the color 
of the precipitate will be determined by it. Blood 
coloring matter makes the precipitate blood-red or 
dichroic : vegetable coloring matter, of rhubarb or 



62 EXAMINATION OF THE URINE. 

senna, etc., pink or blood-red; biliary coloring matter, 
yellowish-brown and uroerythin gray. 

Diseases of bone, malacosteon, rachitis, etc., exten- 
sive periostitis, chronic arthro-rheumatic processes ; 
the introduction of mineral waters rich in calcium, 
medicines and exclusive meat diet (not constant), 
produce an increase of earthy phosphates. 

A diminution is observed in diseases of the kidneys. 

In alkaline urine the earthy phosphates are found 
in the sediment. 

(6) Alkali phosphates are represented (principally) 
by the acid phosphate of sodium and of potassium 
(traces). 

The tribasic phosphoric acid forms three alkali 
salts, depending on 1, 2 or 3 atoms of v hydrogen being 
displaced by the metal : 



P0 4 H 2 Na 


P0 4 H]S T a 2 


P0 4 Na 3 


(Di-hydrogen Sodium 


(Hydrogen Di-sodium 


(Tri-sodium 


Phosphate). 


Phosphate). 


Phosphate). 



Only the first has an acid reaction, and its presence 
produces the acid reaction of urine. The other two 
have an alkaline reaction. All are readily soluble in 
water (in contradistinction with the earthy phos- 
phates), even in alkaline water. 

Of the entire phosphoric acid found in urine, two- 
thirds are bound to the alkalies. 

The reaction is best performed with the magnesia 
fluid (see Chap. IV., No. 10). If we want to examine 
for all of the phosphoric acid in urine, we add to 10 c. 
c. urine 3 c. c. of the magnesia fluid. There is pro- 
duced a precipitate which is made up principally of 



SULPHATES. 63 

ammonium-magnesium phosphate, with which amor- 
phous calcium-phosphate is mixed. If the entire fluid 
becomes milky, the alkaline phosphates are present in 
normal quantity. If the precipitate becomes so dense 
as to give to the fluid the consistency of cream, then 
the phosphates are increased. If the fluid is simply 
turbid and very transparent, then there is a diminu- 
tion. 

This is a reaction for the entire phosphoric acid, but as the 
earthy phosphates are present only in such small quantities, 
they need either not be taken into consideration, or, with a 
little practice, one learns to subtract the quantity found by 
means of the test for the earthy phosphates from the result 
obtained by this test. 

If the earthy phosphates are present in very great 
quantity, they must be precipitated by ammonia, the 
urine filtered, and to this the magnesia fluid must be 
added. 

4. — Sulphates. 

The sulphates found in urine are the neutral sul- 
phates of sodium and potassium. 

The sodium salt, as is the rule every-where, is found 
in greater quantity than the potassium salt. The 
quantity of sulphuric acid passed by the healthy 
adult in twenty-four hours, is between 1.5 and 2.5 
grammes — average 2.0 grammes. 

The reaction for sulphuric acid is performed in a 
manner similar to that for phosphoric acid. Into a 
test-tube is put 10 c. c. of urine, a few drops of hydro- 
chloric acid are added in order to prevent barium- 



64 EXAMINATION OF THE URINE. 

phosphate from being precipitated, then add one-third 
the quantity (3-4 c. c.) of a solution of chloride of 
barium. The reaction takes place according to the 
following formula : 

BaCl 2 +Na 2 S0 4 =2NaCl+BaS0 4 , 

Sulphate of barium being the desired precipitate. The 
solution of chloride of barium can be previously acid- 
ulated with hydrochloric acid (Chap. IV., No. 7), this 
precluding the necessity of acidulating the urine. 

If there is produced an opaque, milky turbidity, 
then the sulphates are present in normal quantity ; if 
the consistency is changed to that of cream, then they 
are increased, and if only a translucent turbidity is 
produced, the sulphates are diminished. 

A very pretty quantitative test has been described by J. 
Vogel, which depends upon the above reaction, and is per- 
formed by taking 100 c. c. of the urine (2.00 grammes of sul- 
phuric acid being voided in twenty-four hours with a quantity 
of 2,000 c. c.) and adding sufficient chloride of barium solution 
to satisfy one-half the sulphuric acid contained in the 100 c. c. 
of urine — i. e., 0.05 grammes. If, upon the further addition of 
the test solution, no precipitate is formed, the sulphates are 
diminished. If a precipitate is produced, add the same quan- 
tity of the test solution that was originally employed, and 
again test. If no precipitate is produced, the sulphates are 
normal, but if a precipitate is produced upon the further ad- 
dition of the fluid, the sulphates are increased. 

An increase of sulphuric acid or- the sulphates is ob- 
served : 

1. After the introduction of sulphuric acid, its 



ALBUMIN. 65 

soluble salts, of sulphur combinations, or of sulphur 
itself, into the organism. 

2. In exclusive meat diet, the sulphur of the albu- 
min being oxidized to H 2 S0 4 . 

3. In acute febrile diseases, accompanied by free 
excretion of urea. Increase in the sulphuric acid 
must, in this case, be referred to an increased waste of 
those constituents of the body which contain sulphur. 
The highest degree is noticed in meningitis, encephal- 
itis, rheumatism, and affections of the muscular sys- 
tem. 

A decrease in the sulphates occurs in exclusive 
vegetable diet, in the beginning of typhus and (in 
percentage) in all those urines that show diminished 
specific gravity. 

Other inorganic substances that have been found in urine 
are ; ammonia, iron and silicic acid. Traces of all, only, are 
found, but for the first, Ducliek claims that as fevers increase, 
so ammonia increases, to diminish in reconvalescenee. 

C. — Abnormal Constituents. 
1. — Albumin. 

Normal urine should never contain albumin. In 
pathological conditions, notably in diseases of the 
kidney, it is frequently found in great quantities. 

After the taking of much egg albumin, CI. Bernard, 
Becquerel and others have observed albumin in other- 
wise perfectly healthy urine. Serum albumin (up to 
0.1%) may be present in the urine of perfectly healthy 
persons. We have reported several cases (Wiener Med. 

E. U.-6. 



66 EXAMINATION OF THE URINE. 

Presse, 1870,), as well as Vogel. The cause for this is 
unknown. The urine, in these cases, was somewhat 
concentrated, very acid, and contained more urea and 
uric acid than normal. In the sediment we some- 
times found nothing, sometimes crystals of uric acid 
or oxalate of lime. It is probable that this albumin- 
uria, periodic and presenting variable quantities of 
albumin, was due to the chemical composition of the 
urine. It might also be attributed to certain abnormal 
nervous conditions of the kidney. At all events, 
these cases are of such rare occurrence that the pres- 
ence of albumin must be considered abnormal. 

Why albumin is not found in the healthy condition, 
is best explained by the mechanical theory of Ludwig. 

Graham divides all bodies into crystalloids and col- 
loids, the former diffusing readily through animal 
membranes; the latter diffusing with difficulty, or not 
at all, and being non-crystallizable. This division, 
applied to albumin, will show that serum albumin is 
a colloid, for it does not crystallize, nor does it pass 
through animal membranes, unless increased pressure 
is applied. The crystalloids passing so readily through 
membranes, and the colloids with such difficulty, it is 
natural to assume that the molecule of albumin must 
be larger than that of any crystallizable salt. The 
probability for this increases when we consider the 
facility with which foam is produced in albumin solu- 
tions, and also its complicated chemical structure. 
The latter finds expression in the formula C 216 H 169 

JN 27^3^68* 

According to Ludwig, we have in the glomerulus, a 



ALBUMIN. 67 

process of transudation, while throughout the course 
of the tubules we have one of diffusion. The two 
fluids, blood and the water of urine, are always found 
separated by animal membrane. These septa have 
the property of allowing the crystalloid substances of 
the blood i >alts, urea. etc. ) to pass through readily, but 
not the albuminoids, under the conditions of pressure 
in the kidneys, therefore we can not expect to find 
albumin in normal urine. 

If we find albumin, then the blood pressure in the 
vessels of the kidney is usually increased (passive 
hyperaemia, valvular heart disease, amyloid degenera- 
tion of the vessels, etc.) or the membrane, in some 
place, has become pervious (parenchymatous nephritis. 
Bright's disease). 

Albumin is found in urine most frequently as 
serum albumin and paraglobulin. If other fluids 
that contain albumin (blood, pus, exudations, etc.) are 
present in the urine we will find that form of albumin 
which is characteristic of these. Fibrin is found in 
copious hemorrhages and croupous affections of the 
urinary apparatus. 

True Lbrinuria, a so-called coagulable urine, that is 
said to occur frequently in Isle de France, is, with us. 
a very rare occurrence. We observed this, temporarily 
only, in three cases of papillomatous tumors of the 
bladder. But we not infrequently find urine having 
the consistency of honey or syrup, depending, how- 
ever, upon pus dissolved in alkalies, not upon fibrin. 
This form of urine becomes thin upon the addition of 
water, and acetic acid produces a white precipitate of 



bb EXAMINATION OF THE URINE. 

albuminate, produced by the action of ammonium 
carbonate on the serum-albumin of pus. 

For albumin there are many characteristic reactions; 
for urine, however, two are of especial value — the 
concentrated nitric acid test, and boiling. 

1. To carry out the nitric acid test, put about 10 c. 
c. of urine into a glass (best a wine or sherry glass) 
and pour under it pure, colorless, concentrated (not 
fuming) nitric acid. 'The reagent is poured under the 
urine by means of holding the glass containing the 
nitric acid at an angle with the one containing the 
urine, and allowing the acid to flow gently along the 
side of the latter. At the place where the acid and 
the urine touch, when albumin is present, a band-like 
zone appears, having both upper and lower boundary 
lines sharply defined. This can only be mistaken for 
resins (copaivic acid) or the urates; the latter, when 
present in great quantity, also precipitate upon the 
addition of nitric acid. This layer, however, does not 
appear where the urine and acid touch, but higher up; 
neither is its upper margin sharply defined, but looks 
more like a cloud of smoke, slightly curly in the 
middle. If albumin and the urates are present at the 
same time, two white layers, superimposed, will be ob- 
tained. The lower one will be albumin, the upper 
one, urates. They are separated from each other by a , 
layer of clear urine. 

The precipitate produced by resins is dissolved by 
the addition of a few drops of alcohol. 

If this test is performed with normal urine, there 
will be observed between the urine and the nitric acid 



ALBUMIN. 69 

a brown ring of coloring matter which, in a few min- 
utes, increases in intensity. We now comprehend 
how. in fever urine, rich in coloring matter, which at 
the same time may contain albumin, the ring of albu- 
min will be, not snowy white, but more or less 
brownish. If much inclican is present the albumin 
frequently appears pink or violet ; in the presence of 
blood-coloring matter, red and with biliary coloring 
matter, not decomposed, of a green color. If urine is 
very much concentrated, there will be produced a 
copious crystalline deposit which, under the micro- 
scope, will reveal itself as nitrate of urea. Urine, rich 
in uric acid, might produce free uric acid in the form 
of yellowish whetstones, which can be readily differen- 
tiated from the preceding precipitate by its insolubility 
in water. 

If urine contains much carbonic acid, either on 
account of its being alkaline and having much car- 
bonate of ammonia, or being neutral or acid, having 
sodium carbonate or free carbonic acid gas (as is fre- 
quently the case during the use of mineral waters), then 
there will be observed, upon the addition of nitric 
acid, an effervescence of the fluid. 

If this test does not convince to satisfaction, then 
the next must decide; indeed, it is always best to per- 
form both tests. 

2. The test by boiling is performed in that we take 
8-10 c. c. of urine, if it be acid, and boil it in a test- 
tube. It is always safer to add 1-2 drops of acetic 
acid. A flaky cloudiness indicates albumin. If the 
urine is neutral, faintly acid or alkaline, a precipitate 



70 EXAMINATION OF THE URINE. 

may show itself on boiling, which, upon the addition 
of acetic acid, again dissolves. This is not albumin, 
but the earthy phosphates that have been held in 
solution by carbonic acid gas, which, being driven out 
by heat, can no longer dissolve them, One thing 
which has only been done as a precaution in acid 
urine, must always be done in alkaline or neutral 
urine to prevent deception, viz: acidulate the urine. 

In this test, albumin is not only simulated, but in 
alkaline urine, may entirely escape detection. The 
nitric acid test frequently fails us here, on account of 
the effervescence produced by the reaction upon the 
carbonates. If we do not acidulate, the alkali present 
may be sufficient to change the albumin to alkali- 
albuminate, which does not precipitate upon boiling. 
If we are not careful with the addition of acetic acid 
we may err on the other side, producing acid-albumin, 
which can not be precipitated by boiling. 

In the presence of very small quantities of albumin, 
its detection becomes a difficult matter if the urine is 
already cloudy, or does not come through the filter 
clear. 

Alkaline urine is already more or less turbid, con- 
tains no earthy phosphates in solution, and must 
always be clarified before proceeding to test for albu- 
min. In order to do this, the urine must be boiled 
with one-fourth its volume of potassium hydroxide 
(Chap. IV., No. 5,) and filtered. If the filtered urine 
is not clear, 1-2 drops of the magnesia fluid must be 
added, and the urine again heated and filtered. If 
this is then carefully acidulated with acetic acid, the 



ALBUMIN. 71 

slightest turbidity of albumin will be detected. This 
becomes more distinct when ferro-cyanide of potas- 
sium is added to the already acidulated urine; white 
flakes of albumin will then be noticed on the bottom 
of the vessel. 

It is advantageous to know other tests. 

(a) Acidulate the urine with acetic acid, add an equal 
volume of a cold saturated solution of sodium sulphate, and 
boil. 

(b) Into filtered urine there is dropped saturated solution 
of picric acid. If cloudiness is produced, albumin is present 
iGalippe's test). Only the cloudiness that is produced in- 
stantly is decisive. 

Albumin is found in urine : 

1. When the blood-pressure in the Malpighian 
tuft is greater than normal. This occurs in all 
anomalies of circulation (valvular lesions of the heart, 
passive hyperaemia, amyloid and atheromatous pro- 
cesses in the arteries, etc). 

2. In all those diseases in which a change in the 
diffusion-membrane, i. e., the walls of the tubule with 
its epithelium and its arterioles and capillaries, can be 
demonstrated (parenchymatous nephritis, Bright's dis- 
ease, etc.). 

3. When there is mixed with the urine, blood, pus 
■ or any other fluid containing albumin (false albumin- 
uria). 

4. Occasionally in hydraemia (disturbance of nutri- 
tion in the capillaries). 

Xote. — High fever seems to produce true albuminuria, It is 
not uncommon to find albumin in the urine of patients 



72 EXAMINATION OF THE URINE. 

suffering with pneumonia, typhoid fever, remittent fever, or 
severe attacks ulcerative sore throat. The diagnosis of diph- 
theria, not being an easy one, the latter instance might be 
referable to an attack of diphtheritis, having been called 
angina ulcerosa. But the two former conditions leave no 
doubt but that albuminuria does occur in some febrile condi- 
tions. If a post mortem be made upon a patient dying from 
either of the two conditions named above it will be surprising 
to rind how little change can be observed in the kidneys. The 
only thing to be found will be cloud}' swelling of the epi- 
thelium, which is frequently observed without having pro- 
duced albuminuria intra vitam. Two explanations can be 
given for the appearance of albumin in the urine : the first, by 
Gerhardt, that the secretion of urine with the temperature of 
the blood at 104° F. at least, must be abnormal ; the second, 
that the specific cause of the fever has acted upon the epi- 
thelium of the kidney, and thus made the transudation of 
albumin a possibility. It is said that albuminuria is produced 
transitorily after epileptic attacks, the quantity of albumin 
varying with the intensity of the attacks, in that it is greater 
after complete, or less after incomplete seizures. 

It is also thought (Vogel) that albuminuria can 
arise from the formation in the blood of a peculiar 
kind of albumin, endowed with different properties of 
diffusion, being even able to pass through the per- 
fectly intact membrane. We have never been in the 
position, however, to verify this view. 

In true albuminuria it is important to be able to 
determine the quantity of albumin excreted in 
twenty-four hours, for only by means of this can we 
determine whether or not improvement is taking 
place. The most accurate quantitative analysis of 
albumin is made by means of the scales or the polari- 



ALBUMIN. 73 

scope (Chap. V.). These methods, however, are too 
laborious, and consume too much time for the prac- 
ticing physician, and we therefore desire a method by 
which we are enabled to state when albumin is present 
in great (1-2%-) or in small Gf%) quantity. This can 
be accomplished, with a little training, by observing 
the albumin zone in the nitric acid test. If this zone 
is faint, whitish, not granular; if it is more or less 
translucent, and only to be distinguished as a sharply 
denned band when placed against a dark background, 
and, above all, is only between 2 and 3 m. m. high, 
we may know that albumin is only present in very 
small quantity (below \%, usually 1 part in 1,000). If 
this zone is between 4-6 m. m. high, white, opaque, 
perceptible without a dark background, and granular, 
then albumin is present in moderate quantity (i~|-%). 
But when, upon the addition of nitric acid, the albu- 
min precipitates in flakes or granules, and sinks to the 
bottom in small masses; when, upon stirring this 
mixture with a glass rod, the urine has the appearance 
and consistency of cream, then the quantity of albu- 
min is very great (1-2% and more). 

Similar results can be obtained with the boiling 
test. 

Fill a test-tube one-third full with clear, filtered 
urine (if alkaline, acidulate with acetic acid). A very 
slight turbidity, which causes the urine to appear 
translucent after boiling, and simply makes it opales- 
cent, indicates a small quantity of albumin. If, on 
boiling, the urine is milky, if the albumin separates 
in fine flakes, and upon settling, makes a layer at the 



74 EXAMINATION OF THE URINE. 

bottom of the test-tube of a finger's height, then albu- 
min is present in moderate quantity. But if the 
albumin coagulates in coarse flakes, and where the 
flame touches the tube, instead of from the upper sur- 
face of the fluid, as before; and if the urine appears 
thick, like cream, after boiling, then albumin is pres- 
ent in very great quantity. 

To compare the quantity of albumin of one day 
with that of another, boil in test-tubes of equal 
diameter, taking equal quantities of urine, and com- 
pare the height of the sediments. It is better to- 
use glass tubes of equal diameter, closed with corks 
wrapped in wax paper. After twenty-four hours we 
can measure, with a rule, the depth of the albumin 
layer. 

The preceding are short directions for approximate 
analysis, but they must be frequently exercised, and 
only he who has made himself perfectly familiar with 
the appearances can draw reliable conclusions. 

What has been said is true for the majority of cases, 
where the principal quantity of albumin is serum 
albumin. 

At the same time, or independently, we frequently 
find modifications of albumin, of which the most im- 
portant is globulin (perhaps myosin). 

Peptone is found in every urine containing albumin ; in 
diseases in which there is a very high temperature it is some- 
times found, even without the presence of albumin. 

In order to detect globulin, we dilute the urine 
until it has reached a specific gravity of 1002. Then 
we carefully add very dilute acetic acid (it is soluble 



SUGAR. 75 

in the concentrated acicl). There usually appears a 
cloudiness. In order to precipitate all the globulin, 
allow a slow current of carbonic acicl gas (bubble after 
bubble) to pass through the urine for 1-2 hours. If 
allowed to stand for a time, the globulin separates in 
the form of a white powder. The fluid can then be 
tested by the other methods for serum albumin. If 
the sediment is made up of globulin, it must be 
soluble in a few drops of concentrated solution of 
common salt. 

Globulin is found in considerable quantities in 
catarrh of the bladder, acute nephritis, and especially 
in the amyloid kidney, whilst it is said that in chronic 
Bright's disease it is present in very small quantity, or 
even entirely absent. 

2.— Sugar. 
(C 6 H 12 6 )-H 2 0. 

The sugar of urine (identical with grape sugar) is,. 
according to Briicke, a normal, constant constituent, 
but it occurs in such small quantity that not even a 
slight yellow precipitate is noticed when Trommer's 
test is used, a discoloration only being observed. In 
abnormal urine, we frequently find so much sugar as 
to sweeten its taste, especially in diabetes mellitus is 
this the case. Clothes which have been moistened 
with such an urine, look, after the water has evapor- 
ated, as if they had been dipped in honey. 

The sugar of urine crystallizes in watery concre- 



76 EXAMINATION OF THE URINE. 

ments, consisting of cauliflower leaflets. Of the many 
tests, the following are usually sufficient : 

1. Heller's Test. — Mix urine in a test-tube with one- 
half its volume of potassium or sodium hydrate solu- 
tion (1 to 3), and boil. First, the earthy phosphates 
are precipitated ;. they can be filtered when present in 
very great quantity. As soon as the fluid is heated, 
its color changes to lemon, yellowish-brown, or brown- 
ish-black, according to the quantity of sugar con- 
tained. If a few drops of nitric acid are added to 
this mixture, the dark color will disappear and an 
odor of caramel become perceptible. If the urine 
. contains much albumin, it is advisable to remove it 
first by boiling. 

If the urine is highly colored, which rarely occurs 
in diabetes mellitus, it can be decolorized with sugar 
of lead solution (the sub-acetate precipitates a small 
quantity of sugar), or by filtering through animal 
charcoal. The latter must afterward be washed with 
water, because it will retain much sugar. 

If this change in color takes place while the urine is cold, 
then biliary coloring matter is usually present. This change 
will even appear when the coloring matter is already decom- 
posed, i. e., when neither Gmelin's nor Heller's tests will in- 
dicate its presence. In this case this test, especially when the 
addition of sulphuric acid produces a very dark color, is a 
very good one for biliary coloring matter. 

According to Badecker, if urine is mixed with caustic 
potassa and exposed to the air, there gradually appears a 
brown discoloration, the urine absorbing much oxygen and 
containing a body which he called alkaptone. This, like 



SUGAR. 77 

sugar of urine, reduces copper, but not bismuth salts. Prob- 
ably this body is pyro-catechine. 

A beautiful reaction is produced by Mulder's test. Mixing 
urine with a solution of indig-carmine, first made alkaline 
with sodium carbonate and boiling, the blue mixture first 
becomes green, then purple, and finally yellow. Shaking the 
boiling mixture and exposing to oxygen, it again comes back 
to the original blue. 

2. Trommels Test. — As before, mix with the urine 
caustic potassa or soda solution, and add drop by drop, 
shaking constantly, a solution of copper sulphate (1 to 
10) until a clear, blue fluid is obtained. Then heat 
over a lamp. If sugar is present, reduction of the 
oxide of copper takes place in the following manner : 
First, yellow cuprous hydrate is precipitated; this 
losing its water, leaves red cuprous oxide. If the test- 
tube is put aside, and we wait a few minutes, there 
will be observed a metallic mirror covering the bottom 
of the tube. Albumin must be removed by coagula- 
tion. If this is forgotten, a violet color, upon the 
addition of the reagents, will be a reminder of its 
presence. If neither sugar nor albumin is present, 
then we get a turbid grayish green fluid, but no re- 
duction of the oxide. 

Large quantities of creatinin, peptone, etc., can prevent the 
precipitation of the cuprous oxide. 

3. Bcettgers Test. — Mix the urine with the alkali, as 
above, then add as much bismuth — a mixture of basic 
bismuth nitrate (BiO)N0 3 +BiO, OH with bismuth 
nitrate (BiO)X0 3 — H 2 — as will cover the end of a 
knife-blade, and then boil. After a time, a mirror of 



78 EXAMINATION OF THE URINE. 

bismuth appears on the test-tube. If small quantities 
of sugar are present, then the bismuth is only colored 
gray, because only a part of it is reduced — the re- 
action may even be covered over by the excess of bis- 
muth. 

If albumin is present, this must be removed, other- 
wise bismuth-sulphide may be produced, which may 
be mistaken for an oxide of bismuth. In order to be 
certain, it is well to add to a portion of urine that has 
been made alkaline, acetate of lead ; if a black precipi- 
tate is formed, it is conclusiA r e evidence of the presence 
of a sulphur compound. 

Briicke recommends, in order to remove all disturbing sub- 
stances, Frohn's reagent (1.5 grammes precipitated, unwashed 
bismuth nitrate are heated to the boiling point with 20 
grammes of water, then 7.0 grammes of iodide of potassium, 
and finally 20 drops of hydrochloric acid added). A modifica- 
tion has been proposed by Maschke, he using a solution of 
tungstate of soda. 

Heller's test is the simplest and the best, and has 
the advantage that with it, one skilled in its use, can 
tell the approximate quantity of sugar present. 
Second comes Boettger's test, for when no albumin is 
present, no other substance except sugar will reduce 
the bismuth. Trommer's test is least reliable, for 
many other substances, when present in the urine in 
large quantities, will reduce the copper salt: uric acid, 
the urates and hippuric acid. Many specimens of 
urine from patients with acute febrile diseases, where 
the urates are present in great quantity, are diagnosti- 
cated as containing sugar, especially if reliance is 



SUGAR. 79 

placed on the yellow discoloration, not waiting for the 
precipitate of cuprous oxide. In all cases, the most 
reliable tests are fermentation and the polariscope, 
both, however, too laborious for the practitioner. 

If the presence of sugar has been demonstrated, it 
is of equal importance to determine the quantity 
present, and the amount passed in twenty-four hours. 
The exact quantitave tests will be discussed hereafter 
— they alone are reliable. The quantity has been ap- 
proximately determined by the specific gravity; the 
higher this is, the more sugar is supposed to be pres- 
ent. This, however, is only true for a pure solution 
of sugar, not for so complex a fluid as urine, and 
Bence Jones has shown that the method can not even 
be utilized for rough estimates. 

The second method is that of Vogel; it depends 
upon the intensity of color produced by the potassa 
test, and is very useful to the practitioner. 

If we make solutions of grape sugar, varying in 
strength, and test them in test-tubes of equal diameters, 
a scale can be easily constructed which will suffice for 
ordinary rough estimates. 

Mix two parts of the solution with one part of 
liquor potassa. and boil. A 1% solution will give a 
canary-yellow: a 2%. a dark amber: a 3%, a dark 
rum. and a 10% solution will become dark brown and 
opaque, while all other solutions are more or less 
transparent. 

Taken in connection with the specific gravity 3 this 
test is very useful, as diabetic urine is usually very 
pale in color. 



80 EXAMINATION OF THE UKINE. 

Sugar occurs in large quantities only in one form of disease : 
glycosuria. It is found temporarily in certain injuries of the 
brain, and is said to appear in very small quantities in the 
urine of acute febrile diseases, spontaneous gangrene, pneu- 
monia, typhus, rheumatism, acute encephalitis, in diseases of 
the nervous system, especially of the cord, in cachexias, and 
similar processes; also after the introduction of turpentine, 
nitro-benzole, nitrite of amyl, etc. 

Neukomm and Vogel, exceptionally, have found inosit, both 
alone and with grape sugar. It is also to be found in Bright's 
disease. 

Some patients suffering with diabetes have a breath that 
smells of chloroform. The urine, odorless immediately upon 
being passed, after a short time also begins to smell of the 
same substance. Upon the addition of chloride of iron, it 
usually turns reddish-brown. In the distillate, of such urine is 
found both aceton and alcohol, the result of the splitting up 
of ethyl-diacetic acid. 

C 6 H 10 O 8 +2H 2 O=C 8 H 6 O+C 2 H 6 O+CO 2 +H 2 O, 
(Ethyl-diacetic acid.) . (Aceton.) (Alcohol.) 

In women, 24-48 hours after ablactation and during nursing 
(when the milk for any reason is not withdrawn sufficiently), 
there appears in the urine sugar of milk. 



III. Leucin and Tyeosin. 
C 6 H 13 N0 2 and (^H^NOg. 

Leucin and tyrosin result from the decomposition 
of albumin and its nearest derivatives. They are 
found in great quantities in certain glandular organs 
of the body, when these are subjected to definite 
pathological changes; in the liver, the pancreas, the 
spleen, etc. In the urine they have been found only 



LEUCIN AND TYROSIN. 



81 



in acute yellow atrophy of the liver, in several cases 
of phosphorus poisoning, and, in small quantities, in 
typhus and variola. 

If these substances are present in large quantity (usually 
the case in acute yellow atrophy of the liver), their detection 
is very simple. Either we find the crystalline tyrosin in the 
urine, or it separates with the leucin, when the urine is con- 
centrated in a water bath. These bodies sometimes occur in 
such great quantity Fig. 4. 

as to partially replace 
urea. They are to be 
recognized by their 
characteristic micro- 
scopic forms. If they 
are not very abund- 
ant, and do not ap- 
pear upon concen- 
trating the urine, a 
large quantity of 
urine must be taken, 
precipitated with 
basic acetate of lead, 
filtered, the excess of 
lead removed by sul- 
phuretted hydrogen, 
again filtered, and «» Leucin ; b, Tyrosin. 

finally, the clear fluid evaporated to a- small volume in the 
water bath. If tyrosin is present, after twenty-four hours a 
crystalline deposit will be observed. Leucin, which is more 
soluble, takes a longer time to be deposited. 

It is necessary to examine the urine as soon as possible after it has 
been voided. 

The presence of leucin and tyrosin in large quantity 
is always an indication of great degeneration of the 
e. u.— 7 




82 EXAMINATION OF THE URINE. 

proteids. Albumin is almost constantly found at the 
same time. Oxymandelic acid (perhaps derived from 
tyrosin) is frequently found in urine, and up to the 
present time it has never been found elsewhere. 

IV. Abnormal Coloring Matter. 

We must here discriminate between those sub- 
stances which, being normal constituents of other 
fluids of the body, would, in urine, be considered ab- 
normal, those that are found only in urine, as uroery- 
thrin, and finally those that are entirely accidental, as 
the coloring matter of plants. 

(a) Uroerythrin (Harley's Urohaematin). 

In all febrile diseases the urine has more or less of a 
yellowish-red color (urina flammea), and the expert, 
in most cases, is enabled from the condition of the 
urine alone to diagnosticate a febrile state. This 
color, according to Heller, comes from the presence of 
uroerythrin (in addition to an increase in the normal 
coloring matter). When such urine has a sediment, 
this is red or dark red; even the clear urine, when 
precipitated with* lead acetate, will cause a pink or 
flesh-colored precipitate of lead. Heller calls this red 
coloring matter, found in solution or in the so-called 
brick-dust sediment, uroerythrin. 

It is said that this coloring matter contains iron ; concerning 
its structure and origin, however, nothing definite is known. 
It is possible that, in diseases in which there is blood dissolu- 
tion (typhus, septic fever, etc.), a part of the blood corpuscles 



COLORING MATTER OF PLANTS. 83 

in retrograde metamorphosis supply material for the forma- 
tion of the uroerythrin. The uroerythrin, then, could be 
taken as measure for the quantity of red blood corpuscles de- 
stroyed during fevers. 

This coloring matter is either discovered by the presence of 
a brick-dust sediment, or, when in solution, by the precipita- 
tion with lead acetate above described. Only a small quantity 
of lead acetate in solution must be added, as it is not advisable 
to dilute the color in a great precipitate. If the urine contain 
blood coloring matter, this must be removed. The foam of 
urine containing much uroerythrin, may be yellow, like that 
of an icteric urine. In the latter, the precipitate with lead is 
also yellow. 

The earthy phosphates, w T hen precipitated with 
liquor-potassa, appear gray, while in urine containing 
blood-coloring matter, they are red or dichroic. The 
absence of albumin, the color of the earthy phos- 
phates and the red precipitate w r ith lead, are the 
points of differential diagnosis between uroerythrin 
and blood-coloring matter. 

Uroerythrin is found in all febrile diseases, even in 
the mildest catarrh; it is found in greatest quantity 
in pyaemia, diseases of the liver and lead colic. 

(/3) Coloring Matter of Plants. 

Many vegetable substances, especially chrysophanic 
acid (in rhubarb, senna, etc.), impart to alkaline urine 
a reddish-yellow to a deep red color. They can be 
recognized in that the red alkaline urine turns yellow 
upon the addition of an acid, but after the addition 
of ammonia again returns to its original' red. In the 
test for the earthy phosphates of such an urine, they 



84 EXAMINATION OF THE URINE. 

will come down colored blood-red, so that one would 
be tempted to think of the presence of blood. But 
the earthy phosphates are never dichroic, and turn 
violet upon exposure to the air. The differentiation 
between uroerythrin and blood-coloring matter is ac- 
complished by the lack of a response to the test for 
blood-coloring matter, "the absence of albumin, and by 
the characteristic changes upon addition of acids and 
alkalies. It is important for the practitioner to be 
perfectly familiar with these tests, especially in sum- 
mer, when the urine is apt to become alkaline, and 
its blood-red appearance be alarming without signifi- 
cation. 

(7) Blood Coloring Matter. 

The occurrence of blood-coloring matter in urine 
may have a double source. Either it is derived from 
the kidneys, or the blood corpuscles that have been 
originally mixed with the urine, have been dissolved. 
The color of the urine varies according as haemoglobin 
or methsemoglobin are present. 

In hemorrhages from larger vessels the urine usually 
contains haemoglobin. In parenchymatous or Capillary 
hemorrhages the urine usually contains rnethsemoglo- 
bin as well, which imparts to it a reddish-brown color. 
The explanation why haemoglobin should occur in 
one place, and methsemoglobin in the other, is prob- 
ably found in the fact that in hemorrhages from the 
capillaries, the urine and blood are more intimately 
and slowly mixed, and are retained longer at the tem- 
perature of the body. 



BLOOD COLORING MATTER. 50 

The most important factors for the change from 
haemoglobin to methaemoglobin are, probably, tem- 
perature, the presence of carbonic acid, and the ab- 
sence of oxygen in the urine. 

For demonstrating blood-coloring matter in the 
urine, the hsemin test is advantageous. Precipitate 
the earthy phosphates in a test-tube ; these will bring 
the blood-coloring matter down with them, and 
appear red. If little of the blood-coloring matter is 
present, they are dichroic. 

If the urine is alkaline, and the test does not bring 
down the earthy phosphates because" of their having 
been already removed with the sediment, we can still 
produce a precipitate with 1 or 2 drops of the mag- 
nesia solution, which will serve our purpose perfectly. 
This precipitate must be collected on a filter, then 
placed upon a slide, and dried carefully by means of 
gentle heat, when the hsemin crystals may be obtained 
directly from it. To this end, place a small quantity 
of common salt upon the dried earthy phosphates, 
and mix well by rubbing with a knife. Then blow 
the excess of common salt from the slide, place a hair 
upon the mixture, and after having added glacial 
acetic acid, cover, and heat until bubbles begin to 
come from under the covering glass. After cooling, 
haemin crystals can be seen with the microscope. In 
order to avoid further decomposition of the blood- 
coloring matter, care must be taken to heat carefully 
with the liquor-potassa, and to filter rapidly. Bubbles 
will also develop under the cover without heating, if 
the slide be allowed to stand, but these are carbonic 



86 EXAMINATION OF THE URINE. 

acid gas, which must be allowed to escape, and then 
heat to the boiling point of glacial acetic acid. The 
crystals prepared in this manner are frequently small 
and imperfectly crystallized, but they can be easily 
distinguished by using higher powers. 

Another method consists in making the nrine alkaline with 
caustic soda, and adding first tannic, and afterwards acetic 
acid. The washed and filtered precipitate is then tested for 
hsemin crystals. 

The crystals may be obtained, also, by coagulating 
the albumin, collecting this brown coagulum upon a 
filter, drying, and testing with alcohol which contains 
sulphuric acid. After the alcohol has been evaporated, 
the residum should be tested in the above manner for 
Teichman's hsemin crystals. 

If we have a spectroscope at our disposal, a large 
test-tube should be filled w r ith diluted urine, and 
placed between a lamp and the instrument, when the 
characteristic spectrum can be observed. 

So-called hsematinuria occurs in diseases of the 
general system, scorbutus, purpura, scarlatina, etc., 
after transfusion of blood, after inhalation of arseniu- 
retted hydrogen — that dissolved blood-coloring matter 
is found in cases of true haematinuria, need hardly be 
mentioned. 

(rf) Biliary Coloring Matter. 

In certain conditions, biliary coloring matter, de- 
composed or other wise, ca$ be found mixed with 
urine. The urine contains biliprasin more frequently 



BILIARY COLORING MATTER. 87 

than bilirubin; frequently, also, other results of oxida- 
tion of biliary coloring matter. If bilirubin is pres- 
ent unchanged, the proper tests will give a beautiful 
and characteristic play of colors; if biliprasin is pres- 
ent, these will produce only a green color; but if the 
coloring matter has been changed beyond this, the 
tests are negative. 

For the detection of unchanged biliary coloring 
matter (bilirubin and biliprasin), the following tests 
may be used: 

1. Gmelin's Test. Pour under icteric urine concen- 
trated nitric acid, containing a small quantity of 
hyponitric acid. When the two fluids touch, the fol- 
lowing colors in the following order will appear: 
green, blue, violet, red, yellow. This test can also be 
performed by mixing urine with dilute nitric acid, 
and then pouring concentrated sulphuric acid under 
the mixture. 

2. Heller's Test. Pour into a small beaker 6 c. c. of 
pure hydrochloric acid, and then add urine, drop by 
drop, until the acid becomes faintly colored. Mix, 
and then pour pure nitric acid under the mixture. 
Again the play of colors will be observed when the 
fluids meet. If the fluids are mixed together, this 
play of colors will take place throughout the whole 
mixture. The play of colors can ,be especially well 
observed by means of transmitted light. This test is 
very delicate, easily executed, and sufficient for almost 
all cases. 

To detect small quantities, it is necessary to shake 
100 c. c. of urine with 10 c. c. of chloroform in a 



OS EXAMINATION OF THE URINE. 

l)ottle until the fluid is tinged yellow. Avoid too 
^energetic shaking, as that will subdivide the chloro- 
form so finely that it will no longer unite in large 
drops. Closing the bottle with the thumb, and lifting 
the latter, it is easy to allow 1 c. c. of chloroform to 
drop into a test-tube containing 10' c. c. of hydro- 
chloric acid. If a small quantity of nitric acid is then 
added, and the whole shaken, the characteristic play 
of colors of Gmelin's test will be observed in the drop 
of chloroform. Because this play of colors takes place 
very slowly, and because acids act very slowly upon 
the coloring matter dissolved in chloroform, this test 
is especially valuable for the purpose of demonstra- 
tion. 

In all reactions for biliary coloring matter, the green 
color is the deciding tint. If this has not been ob- 
served, the presence of biliary coloring matter can not 
be deduced. Indican, for instance, will also give blue, 
violet and reddish-yellow, with Heller's test, but the 
characteristic green is wanting. 

In testing for albumin with the nitric acid test, if unchanged 
biliary coloring matter is present, a green zone will be observed 
between the urine and the colorless nitric acid. If albumin 
is present, it is colored green by this test. Urine containing 
indican, may, however, even here, simulate biliary coloring 
matter. A blue layer is produced, which looks green by 
reflected light. In these cases, either perform Heller's test 
with the chloroform, or precipitate the urine with lead acetate, 
and see if it is possible to detect indican, in appreciable quan- 
tity, in the filtrate. 

Ultzmann's Test. This strives to bring out the char- 
acteristic green color positively and surely. Add to 



BILIARY ACID. SV 

10 c. c. urine 3-4 c. c. solution of potassium hydrate 
(1 in 3 of water), shake, and acidulate with pure hydro- 
chloric acid. The mixture turns emerald green. 

If the earthy phosphates are precipitated from urine 
containing biliary coloring matter, they come down 
with a brown color. 

When the coloring matter is so much changed that 
the preceding tests are negative, the following will be 
of service : Dip a piece of clean, white linen (or filter- 
ing paper) into the urine, and allow to dry. The 
linen will appear brown. 

A further proof of the presence of biliary coloring 
matter will be found in a very dark sulphuric acid 
reaction. The urine does not become garnet, but 
black. A similar reaction will only be observed when 
sugar or blood-coloring matter is present. Both are 
to be previously excluded. 

With potassium hydrate the earthy phosphates are 
precipitated of a brown color. 

Biliary coloring matter is found in urine, independ- 
ently of jaundice, in a variety of pathological changes 
of the liver, so that that disease can frequently be pre- 
dicted several days before its appearance, from the 
urine. Furthermore, the biliary coloring matter is 
always found in phosphorus poisoning. 

V. Biliary Acids. 

These are rarely found in urine, and then only in 
small quantity. In jaundice, although the coloring 
matter of the bile may be present in great quantity, 
thev are very rarely found. 



90 EXAMINATION OF THE URINE. 

In diseases of the parenchyma of the liver, accom- 
panied by rapid destruction, they are undoubtedly 
found, but even then in small quantity. In such 
cases it must be accepted that such large quantities 
of the biliary acids are produced, that they can not 
undergo the normal changes in the blood, and are, 
therefore, found in the 1 urine. 

It is sometimes possible to demonstrate these acids 
by means of Strassburger's method : Dissolve a small 
quantity of cane sugar in the urine that is to be tested,, 
dip filtering paper into it, and allow to dry. Going 
over this with a glass rod, dipped in sulphuric acid r 
which must be free from nitric acid, will produce a 
purple-violet stripe; red or reddish-brown is not de- 
cisive. 

It is necessary, as a rule, to separate the biliary acids, 
in a pure state, from a large quantity of urine, and 
perform Pettenkofer's test. 

The separation is very laborious. Evaporate about 500 c. c. 
of urine to dryness, in a water bath, and extract with ordinary 
alcohol. This solution is again evaporated, and the residuum 
extracted with absolute alcohol. This alcohol is again dissi- 
pated and the solid treated with water, the solution precipi- 
tated with acetate of lead, avoiding an excess ; the precipitate 
collected, washed, and dried with filter paper. Thereupon, 
the salts (with lead as base, and biliary acids as acids) are 
extracted with boiling alcohol ; sodium carbonate is added, 
again evaporate, and, finally, the resulting sodium salt of the 
biliary acid is extracted with absolute alcohol. Now permit 
. the alcohol to evaporate, and perform Pettenkofer's test with 
the concentrated watery solution. 

This test is based upon the fact that all watery solutions 
of the biliary acids, if mixed with a concentrated solu- 






CARBONATE OF AMMONIUM. 91 

tion of cane sugar and concentrated sulphuric acid, will 
produce a violet-purple color, when they are not heated over 
70° c. (158° F.). It is best to put the test-tube into cold water 
as soon as sulphuric acid is added, otherwise the sugar will be 
charred by the acid, and produce a black color. 

A trace can be detected by Xeubauer's modification ; a few 
drops of the suspected fluid are evaporated to dryness on a 
porcelain dish, upon the water bath. A minute drop of solu- 
tion of cane sugar is added (1,00 gr. sugar in 500 c. c. water), 
and an equally large drop of concentrated sulphuric acid. 
This must be heated over the water bath, until the violet 
color begins to appear at the circumference, when the dish 
should be taken from the bath, and the reaction will become 
more marked. 

Many other substances, such as amyl alcohol, albu- 
min, oleic acid, give the same reaction, but they can 
be differentiated by means of the spectroscope. 

Besides the substances treated of, allantoin will appear in 
urine, especially after the administration of tannic acid ; lactic, 
acetic, and butyric acids occur in cases of acid fermentation ; 
and benzoic acid in putrid urine, as well as fats and soaps. 

VI. Carbonate of Ammonium. 

C0 3 (NH 4 ) 2 

All the carbonate of- ammonium that occurs in 
urine, comes from urea, which, as has been before 
stated, is carbamid. 

CO j *J** 2 =UREA. 

This is changed to ammonium carbonate by taking 
up water. 




92 EXAMINATION OF THE URINE. 

(NH 2 

(nh 2 

The development of ammonium in the decomposi- 
tion of nrine by putridity, which may occur in the 
bladder, is caused by this reaction. The ferment is a 
body which adheres to the mucus of the bladder, and 
develops best during a catarrh. We, therefore, find 
the urine reacting alkaline in nearly all diseases of 
the bladder. The catarrhal secretion of the pelvis of 
the kidney does not seem to cause alkaline fermenta- 
tion, at least, not immediately ; consequently, we find 
the urine in pyelitis nearly always of an acid reaction. 
If fresh normal urine be mixed with the sediment 
of urine from a pyelitis, and another specimen with 
that of cystitis, it will be seen that the former will 
require between twelve and twenty-four hours to 
show alkalinity, while the latter will become alkaline 
in a very short time (two to three hours). 

Ammonium carbonate is also found in the second 
stage of processes with exudation, so-called absorption- 
urine, and is considered, here, a favorable symptom. 
This substance can be recognized by its odor. 

Urine containing it, moreover, is usually alkaline. 
But the alkaline reaction may depend upon a fixed 
alkali, as sodium carbonate, which has been taken 
internally. Whenever there is any doubt about the 
nature of the alkalinity, the following test can be 
used: 

Put into a small Florence flask, 15 to 20 c. c. of the 
urine, then close the flask with a cork, perforated, in 



HYDROGEN DI-SULPHIDE. 93 

order to allow a glass tube, of the thickness of a lead- 
pencil, to pass through. Into this there is put a piece 
of red litmus paper that has been well moistened. 
Heat the flask carefully in a water bath; if ammonia 
is present, it will be carried off with the vapor of water 
arising from the urine and color the litmus paper blue. 
Care must be taken not to boil the urine, otherwise 
urea will be decomposed, giving rise to ammonium 
carbonate. 

Ammonium carbonate is found : 

1. Usually in the various forms of disease of the 
bladder. 

2. In the second stage of acute exudative processes. 

According to Heller, this salt is also found in troubles of the 
spinal cord and grave cases of typhus, even with acid reaction 
of the urine. 

VII. Hydrogen Di-Sulphide. 
SH 2 

Occasionally sulphuretted hydrogen is found in urine con- 
taining albumin, especially in troubles of the bladder, where 
a great quantity of pus is produced. Here it is formed from 
the albumin, which decomposes while in the bladder. Al- 
though the odor is characteristic, yet it sometimes becomes 
necessary to prove its existence by a chemical reaction, In 
order to do this, we use the same method employed for 
detecting the presence of ammonia, taking, instead of the 
litmus paper, a piece of filtering paper that has been dipped 
either into a lead or silver salt solution. The slightest amount 
of heat will cause the gas to escape and color the strip of paper 
brownish-black . 

Such urine is easily detected by the fact of its coloring silver 
catheters black. 



94 EXAMINATION OF THE URINE. 



Accidental Constituents. 

Under this heading we consider those substances that are 
exceptionally found or introduced into the organism, and then 
leave it by way of the urine. 

Many substances are not changed at all in the system, as 
most inorganic combinations, as well as many organic (suc- 
cinic acid, chloroform, quinia, carbolic acid, etc.). 

Of the heavy metals, the following have been found: anti- 
mony, arsenic, copper, zinc, gold, silver, tin, lead, bismuth, 
and mercury; either as a result of introduction as medicine, 
or on account of constant handling (painters, potters, etc.). 

Of the alkali salts nearly all pass into the urine ; the car- 
bonates, ammonium salts, chlorates, borates and silicates of 
the alkalies, ferro and ferri-cyanide of potassium, cyanide of 
potassium, iodide of potassium, etc. Potassium sulphide is 
found in the urine as sulphate. On the other hand, calcium 
and magnesium salts are either not found at all, or only in 
very small quantities. 

Mineral acids (sulphuric, nitric, phosphoric, etc.) are found 
as corresponding alkali salts; free carbonic acid, only, appears 
as a simple solution in urine. 

Metallic bases can be detected, either by electrolysis, or by 
forming an ash, and examining in the ordinary way. Arsenic 
is first precipitated in the ordinary way, and can then be 
easily detected by Marsh's method. 

Many combinations, the organic ones, especially, are 
changed in the organism. The aromatic acids, for instance, 
are all excreted in the urine, as glycocol combinations ; ben- 
zoic acid as hippuric acid; salicylic acid, for the most part, as 
salicyluric acid. 

Carbonates of the alkalies are found : 

1. After the internal administration of the same. 

2. After the use of mineral waters. 






FERMENTATION OF URINE. 95 

3. After eating much fruit, because the fruit acids are all 
converted into carbonic acid in the system. 

In these cases the reaction of the urine is alkaline. In 
order to prove the origin of this alkalinity, evaporate to dry- 
ness, then add a little water, and test with litmus paper. If 
there is an alkaline reaction, it is proof positive that there 
have been permanent alkali salts present in the urine. 

Iodine is easily detected by adding carbon di-sulphide to 
the suspected urine, and then fuming nitric acid or bromine 
water and shaking (violet discoloration of the carbon 1 di-sul- 
phide or chloroform). A bluish discoloration indicates iodine. 
In Heller's test for albumin, iodine crystals are frequently de- 
posited. 

Salicylic acid can be detected by the violet color produced 
when ferric chloride is added. A similar reaction sometimes 
occurs in diabetic urine, even when salicylic acid is absent. 

D. — Sediments. 
Fermentation of Urine. 

Normal urine is clear when voided. After standing 
for some time, the so-called nubecula is found, either 
at the bottom of the vessel or in the lower part of the 
urine; a cloud of mucus from the bladder, which is 
very well marked when relieved by a dark back- 
ground, or when the mucus contains epithelium, an 
abnormally large quantity of bacteria, or traces of 
precipitated urates, held in suspension. 

In this condition, healtlw urine will keep for a long 
time, in a perfectly clean vessel; longer when the air 
is excluded — for weeks, even months. Frequently, 
however, a change takes place, known as acid fer- 
mentation. 



96 EXAMINATION OF THE URINE. 

Both the acid sodium phosphate and the urate of 
sodium are found in urine. 

The phosphate acts upon the urate, by withdrawing 
some of its base, and changing it to an acid salt, which, 
being insoluble, is precipitated as a yellow or reddish 
powder. This reaction takes place most readily at a 
low temperature. At high temperatures the process 
of decomposition goes on. All the base (sodium) being 
withdrawn from the urate, and the uric acid set free, 
it, being comparatively insoluble, comes down in the 
form of a crystalline granular powder, with a brick- 
dust or brownish-red color, which adheres to the walls 
of the vessel, floats on the surface of the fluid, or rests 
on the bottom. Sometimes these uric acid crystals 
are mixed with amorphous urates, which have not, as 
yet, been decomposed — brick-dust sediment. 

During this process no free acid is produced, as may 
be proved by appropriate tests. 

In the greater number of instances, calcium oxalate, 
in small or large crystals, is mixed with this sediment. 

Some of the uric acid is transformed in the body, 
into oxaluric acid; this, when exposed to the air for 
some time, changes to oxalic acid, appearing in the 
sediment as oxalate of lime. 

This process, as will be seen, does not deserve the name, 
fermentation. But in some cases true fermentation, with the 
formation of acetic acid, takes place. 

After this process has come to an end, there begins, 
sooner or later, another. The urine becomes paler, 
the crystals of uric acid have disappeared, acid reaction 



FERMENTATION OF URINE. 97 

gives way to neutral, which finally changes to alkaline. 
The urine has an ammoniacal odor, becomes very 
cloudy, and has a white precipitate, made up of phos- 
phates of the earthy alkalies. Under the microscope, 
this cloudiness will be seen to be made up not only 
of suspended phosphates, but also of innumerable 
bacteria, at rest and also in motion. This process is 
actual or alkaline fermentation. The cause is the 
decomposition of the urea, it being acted upon by a 
peculiar ferment, discovered by Musculus. 

Musculus recommends paper impregnated with the ferment, 
as a very delicate test for urea. The thick alkaline urine, 
which occurs in cystitis, must first he filtered. The paper used 
for filtering is washed with distilled water until it no longer 
reacts alkaline, and is then dried and colored with tumeric. 
Urea does not react upon turmeric, but when the ferment 
in the paper acts upon urea, the latter is decomposed, and 
the ammonium carbonate, thus generated, colors the paper 
brown. 

Xote. — Acid fermentation is supposed to be produced by a 
fermentation fungus. This fungus can be seen under the 
microscope, in the form of small, highly refractive, spherules. 
Alkaline fermentation is caused by the development of the 
micrococcus ureae (Pasteur). It presents itself, under the 
microscope, in the form of rods, which, later in their develop- 
ment, become cocci, looking like a string of beads. Musculus 
has been able to isolate a ferment from the mucus secreted by 
bladders affected with catarrh. An aqueous solution of this 
substance causes a splitting up of urea into ammonia and car- 
bonic acid gas. As, however, the microccus ureae is present 
wherever there is alkaline fermentation of urine, and as it 
will also cause the splitting up of urea, it is fair to surmise 
that the micrococcus produces the ferment of Musculus, and, 
by means of the latter, causes the change in urea. 

E. U.-8 



98 EXAMINATION OF THE URINE. 

The ammonium may unite with the uric acid to 
form ammonium urate. When the formation of am- 
monium has reached its maximum, a part of it unites 
with the magnesium phosphate to form crystals of the 
triple phosphate. Calcium phosphate, which is soluble 
only in acid solutions, is precipitated, and we have 
the sediment of alkaline urine, composed of amorphous 
masses of calcium phosphate, crystals of triple phos- 
phate, and, in the beginning, of ammonium urate. 

Pus, blood or vessels already unclean with urine 
that has fermented, cause very rapid decomposition of 
the urine, it not being necessary for the urine to go 
through the so-called acid fermentation first. 

The process is accompanied by bacteria. Various 
fungi can be observed upon the surface of the urine, 
especially in warm weather. 

Classification of the Sediments. 

As long as these formed constituents of urine are 
mixed with the urine, they cause cloudiness; as soon 
as they sink to the bottom, a sediment. Precipitation 
takes place variously ; quickly in thin urine, contain- 
ing heavy substances, such as uric acid or urates; 
slowly in albuminous, dense urine, containing light 
substances, such as epithelium or hyaline casts. The 
constituents of the sediments are either formed inside 
or outside of the body. The elements are either organ- 
ized (occurring both in acid and alkaline urine) or 
unorganized, partly amorphous, partly crystalline ; 
some found in acid, others in alkaline urine. Accord- 
ingly, the sediments can be divided as follows : 



URATES. 99 

SEDIMENTS. 
I, of acid urine. II, of alkaline urine. 

A. — Non-Organized. 

(a) Amorphous. 

1. Urate of sodium and potassium. 1. Calcium phosphate. 

2. Fats. 2. Calcium carbonate. 

(b) Crystallized. 

1. Uric acid. 1. Ammonium urate. 

2. Calcium oxalate. 2. Triple phosphate. 

3. Cystin. 3. Calcium phosphate. 

4. Tyrosin. 4. Magnesium phosphate. 

B. — Organized. 

1. Mucus and pus corpuscles. 

2. Blood corpuscles. 

3. Epithelium from the various 

parts of the urinary apparatus. 

4. Casts and coagula of fibrin. 

5. Spermatozoa. 

6. Cancer tissue. 

7. Entozoa. 

8. Fungi. 

They will be discussed in this order. 

Non-Organized Sediments. 
I. Urates. 

In urine uric acid is found bound to sodium and 
potassium, and with them forms salts of variable 
structure; so that, by the withdrawal of base, more 



100 EXAMINATION OF THE URINE. 

acid salts are produced, which become less soluble, 
and, consequently, more ready to precipitate. 

Urates are more soluble in warm than in cold water; 
the neutral salts are more soluble than the acid. > From 
this, it follows, that when stronger acids are added, 
which displace part of the uric acid from its base, acid 
(less soluble) salts are produced from the neutral ones. 
The colder the fluid, and the smaller its quantity, the 
more rapidly these are precipitated. The formation 
of a sediment of urates is favored, then, by the follow- 
ing conditions: 

1. Moderate addition of acid (uric acid is precipi- 
tated by a great acidity), or the action of acid salts 
(so-called acid fermentation). 

2. Concentration of urine, either from an increase in 
uric acid, or by a diminution of water. 

3. Cooling of the urine, which only takes place 
naturally after it has been voided, or in the cadaver. 

The urates of the alkalies are an amorphous powder, 
which, on account of the coloring-matter that comes 
down with them, appear yellowish, grayish, brown, 
pink, or brick-dust red. Under the microscope they 
appear as small granules, grouped together like moss. 
If mixed with mucus, the beginner might mistake this 
picture for that of a finely granular cast. They can 
be differentiated, however, by the absence of sharp 
contours, b^ the want of plasticity, and, above all, by 
the reaction upon the addition of heat. 

The urates disappear when warmed. Any deposit 
that is left, will be found to be pure uric acid. Even 
this disappears on the addition of an alkali and heat. 



AMMONIUM URATE. 101 

This property of the urates permits a differentiation 
between pus and the phosphates, without the use of 
the microscope. Phosphates do not occur in urine of 
a decidedly acid reaction. In faintly acid urine, boil- 
ing would increase the deposit, especially if potassium 
or sodium hydrate were added. 

If the urine contains pus, boiling, alone, would not 
make it clearer; on the contrary, because of the coagu- 
lation of the albumin, the deposit would become denser 
(alkalies, however, would probably prevent this coagu- 
lation). 

Finally, the murexid test, performed with the dry 
sediment, or the following beautiful microscopic test, 
would be decisive. Add to urates, which have been 
placed upon a slide, a drop of hydrochloric acid ; after 
a time, crystals of uric acid will appear. 

In urine that has undergone acid fermentation, and in 
which the alkaline fermentation has been begun, we some- 
times observe crystals of uric acid, partially dissolved, but 
having prismatic crystals of sodium urate deposited upon 
them. 

II. Ammonium Urate. 

Acid ammonium urate is the 011I3 7 urate which 
occurs in alkaline urine, and it is, therefore, found 
side by side with amorphous calcium phosphate and 
the triple phosphate. 

Ammonium urate forms brown balls, which are 
either developed singly, doubly, or in the form of a 
conglomerate, with a kidney-shaped surface. The 
surface of these bodies is either smooth, or covered 



102 



EXAMINATION OF THE URINE. 



with small spikes, which are sometimes long, even 
divided, and then, Fige 5> 

most frequently, 
curved, producing 
manifold forms 
(Fig. 5). These 
forms are so char- 
acteristic that 
there can be no 
doubt concerning 
the nature of the 
crystals when 
viewed under the 
microscope. 

Other tests are 
the murexid, the 
formation of uric 
acid as described above, and, finally, the addition of 
caustic potassa, producing bubbles of liberated am- 
monium. 

III. Uric Acid. 




Ammonium Urate. 



The occurrence of uric acid is due, partly, to the 
same causes that have been discussed under the 
head of urates. Normally, crystals of uric acid are 
found at the termination of so-called acid fermenta- 
tion, in concentrated urine, especially in summer, 
where high temperature prevents the deposit of urates; 
then, in pathologically increased formation of uric 
acid, in which case neither water nor alkalies suffice 
to keep the acid in solution. 



URIC ACID. 



103 



The primary form of uric acid is that of rhombic 
plates with rounded, blunt corners. 

This form is known as the whetstone. The crystals 
may be very small or developed singly. Sometimes 
they group about foreign bodies, as threads, hairs, and 
then form cast-like Fig. 6. 

bodies. At other 
times the individ- 
ual crystals are 
highly developed 
and collected to- 
gether, appearing 
either fan-shaped 
or like shingles 
upon a roof. Be- 
sides this, barrel- 
shaped, and, in 
other cases, lance- 
shaped crystals, 

frequently United Uric Acid _ a< Rose tte ; Z>,Whetstone ; c, Dumb- 
tO form rosettes De H- : ^> Barrel-shaped; e, Lance-shaped. 

are found. The rough and lance-shape forms are of 
great practical importance, as they always have some 
connection with the formation of calculi in the kid- 
ney. They only occur in very acid urine. When 
this is counteracted by the internal administration of 
fixed alkalies, the form of the crystal changes to the 
normal, that of the whetstone. These forms are fre- 
quently found in the sediment of pyelitis' calculosa, 
and also accompany albuminuria (hyperemia of the 
kidneys) and hematuria. Intense desire to pass 




104 



EXAMINATION OF THE URINE. 



water, without albuminuria or pyelitis, is occasionally 
found in patients whose urine contains these forms. 

In all cases the uric acid appears colored; faintly 
yellow, brownish red or dark brown, on account of 
coloring matters which are brought down with it. 

The crystals are usually so well developed that they 
appear like glistening brick-dust red sand upon the 
bottom of the vessel, and may be diagnosticated with 
the naked eye. This sediment is dissolved in caustic 
alkalies. 

IV. Calcium Oxalate. 

Oxalic acid has great affinity for calcium. As there is 
calcium in urine, Fig. 7. 

the oxalic acid 
formed in the kid- 
ney, or in the 
urine, must be 
found in the latter 
in the form of cal- 
cium oxalate. 

These crystals, 
as has been stated, 
frequently appear 
with uric acid dur- 
ing acid fermen- 
tation. The crys- 
tals of calcium- 
oxalate are of a 
very characteristic shape. They are flat octahedra, 
which refract the light very much ; sometimes having 




Calcium Oxalate and Cystin.— a, Cystin; b, 
Calcium Oxalate. 



CYSTIN. 105 

the appearance of small points, sometimes of squares, 
whose corners are connected by diagonals, which 
make them look like envelopes. (See Fig. 7.) Besides 
this form, there is also that of the hour glass (dumb- 
bell). These crystals easily escape detection by the 
inexperiened, on account of their low specific gravity, 
which causes them to be very slowly deposited. The 
urine must be allowed to stand from twelve to 
twenty-four hours, to allow them to settle. 

The characteristic form of these crystals prevents 
error in diagnosis. The only crystal which could be 
mistaken for them is the triple phosphate, but that is 
always larger than the calcium oxalate, and is always 
found in neutral or alkaline urine, whilst the cal- 
cium oxalate is only present in an acid urine. And, 
finally, acetic acid dissolves the triple phosphate, and 
not the calcium oxalate. 

V. Cystin. 

Cystin forms regular hexagonal plates, varying in 
size, and arranged either singly, or with one or more 
smaller crystals lying upon a larger one. Sometimes 
a large crystalline plate shows cleavage corresponding 
to the outline of a hexagon. Twin crystals are of rare 
occurrence, and small, poorly developed crystals are 
collected together in irregular masses. (See Fig. 7.) 

Sometimes the corners of the crystals are rounded, 
as if they had been melted off. The crystals are 
always colorless, and can only be mistaken for an ex- 
ceedingly rare form of colorless uric acid. This latter 



106 EXAMINATION OF THE URINE. 

possibility might arise if dissolved cystin had been 
precipitated from the urine by acetic acid, producing 
a similar, but more irregular deposit of uric acid, in 
hexagonal plates, hardly as regularly formed as those 
of cystin. > 

In order to prove whether the crystal under the 
microscope is cystin, allow a drop of ammonia to flow 
under the thin cover; with this treatment cystin would 
immediately disappear, whilst uric acid would remain, 
unless heated. As soon as the ammonia has evapo- 
rated, the cystin crystallizes again; this process may 
be hastened by adding a drop of acetic acid to the 
ammoniacal solution. 

A second test consists in adding a drop of hydro- 
chloric or oxalic acid to the crystals. This dissolves 
cystin, while uric acid remains unchanged. It can 
not be mistaken for the urates on account of its form, 
and because it is entirely insoluble in warm water. 

As cystin is soluble in ammonia, but not in am- 
monium carbonate, alkaline fermentation precipitates 
it as it does the earthy phosphates. From these it can 
be differentiated both by microscopic and chemical 
tests. 

Acetic acid dissolves the earthy phosphates, but 
leaves the cystin unchanged. When this mixture is 
boiled, the greater part of the sediment sometimes 
dissolves, and the remnant may reveal hexagonal 
plates, under the microscope, which must be tested 
with ammonia and hydrochloric acid, in order to 
separate the cystin from the uric acid which may be 
present. 



LEUCIN AND TYROSIN. 107 

Cystin which has been dissolved in liquor potassa, 
heated, and mixed first with water and then a solution 
of sodium nitro-prusside, will turn violet (sulphur 
reaction). 

Urine containing cystin is usually pale; upon de- 
composition the odor of sulphur, besides that of am- 
monia, is developed ; this is probably because of the 
presence of sulphur in cystin. The sediment is found 
in company with a cystin calculus, and also alone. It 
appears white, or grayish, mixed with triple phos- 
phates and calcium phosphate, and in acid urine with 
calcium oxalate. 

With us this sediment is very rare, but it is said 
that cystinuria has frequently been observed in several 
members of the same family. 

VI. Leucin and Tyrosin. 

' (See Fig. 4, Abnormal Constituents.) 

Leucin appears under the microscope in the form of 
more or less colored spheres, of various sizes, which 
resemble fat globules. Their contours are sharp, and 
with a good light they show radii and delicate con- 
centric lines. 

Tyrosin forms very fine, short needles, which cross 
each other and collect in groups, which lie upon each 
other in such a way as to form crosses. Sometimes it 
is found as a sediment, but more commonly we find 
globules of leucin mixed with it. 

Mistakes between leucin and fat globules can be 
avoided by testing with ether, in which fat is soluble, 



108 EXAMINATION OF THE URINE. 

and leucin, insoluble. The crystals also dissolve in 
potassium hydrate, but not in cold mineral acids. 

Tyrosin crystals can be verified in two ways; by 
Piria's and by Hoffman's test. The first method con- 
sists of putting a small quantity of sediment into 
a watch glass and moistening it with two or three 
drops of concentrated sulphuric acid; this must stand 
twenty or thirty minutes, when water is first added, 
and then calcium carbonate, until effervescence ceases, 
after w T hich the whole must be filtered. If, on the 
addition of ferric-chloride (free from acid), a violet 
discoloration takes place, the sediment is tyrosin. 

The second method is simpler. Pour water over the 
sediment, and boil. To the boiling fluid, add a drop 
of a solution of mercuric nitrate. A red precipitate 
is formed, and the fluid changes to pink or purple. 

Leucin and tyrosin are seldom found in urine, and 
when they do occur, it is nearly always in cases of 
acute yellow atrophy of the liver, or in phosphorus 
poisoning. 

VII. Fat. 

One must be very careful not to consider the film of 
fat which is found upon urine, as a product of the 
urinary organs. We can satisfy ourselves in every 
case, that it is the result of the introduction of the 
catheter. We must be equally cautious in regard to 
finely divided drops under the microscope. Thejr are 
usually the result of some foreign admixture, as oil 
in the vessels in which the urine has been preserved ; 
fat upon the slide, milk, etc. 






EARTHY PHOSPHATES.' 109 

The statement that a high degree of fatty degenera- 
tion in the kidney will produce fat globules in the 
urine, is one which, as a result of observation, we can 
not confirm. A priori this is not probable, on account 
of the fact that that part of the kidney which is fatty 
does not excrete urine; this view also requires the 
assumption that the fat is separated from the kidney 
in the form of drops. That this is not the case, can 
be shown upon the post-mortem table. 

Emulsified fat is found in the chylous urine of the 
tropics, whose turbidity, inasmuch as it depends upon 
fat, can be made to disappear readily by ether. It 
never forms a sediment, but, on account of its low 
specific gravity, is found, like cream, upon the surface 
of the urine. 

Under the microscope, fat shows globules with very 
sharp outlines, which ether dissolves. 

Cholestearin is found simultaneously with the fats ; 
this occurs rarely, however, and then only in its crys- 
talline form. It is recognized by its characteristic 
crystal form, transparent rhombic plates. 

Galacturia is very rarely met with in temperate 
climates. 

VIII. Earthy Phosphates. 

(a) Amorphous. 

A layer of grayish-white sediment is frequently 
found in ammoniacal urine, which the beginner might 
mistake for pus ; it consists of the precipitated earthy 
phosphates, i. e., calcium and magnesium phosphates. 



110 EXAMINATION OF THE URINE. 

1 

As has been stated, these salts are only soluble Jin 
acid fluids; they, therefore, precipitate as soon as the 
urea is split up, causing alkalinity of the urine. 

The earthy phosphates appear, under the micro- 
scope, like granules of varying size, unlike the urates, 
however, in configuration. Differentiation can easily 
be effected by chemical tests. 

The urates, with the exception of ammonium urate, 
occur in acid urine, whilst the earthy phosphates, ex- 
cepting the crystallized calcium phosphate, are only 
found in alkaline urine. The litmus reaction is thus 
sufficient to solve the question of urates or phosphates. 
An addition of sodium or potassium hydrate will 
dissolve the urates, whilst phosphates will remain un- 
changed. 

Differentiation between pus and the phosphates will 
be discussed further on. 

All causes for alkalinity of urine produce this sedi- 
ment, which varies according to the quantity of earthy 
phosphates originally held in solution by the urine. 

In exceptional cases, in diseases of the bladder, and 
when great quantities of alkalies are taken internally, 
the urine is passed alkaline in reaction. When this 
occurs, it is turbid, because the precipitation of the 
phosphates had taken place in the bladder ; as a rule, 
precipitation takes place after the urine has been 
passed. 

The so-called triple phosphate, in its characteristic 
form, is always mixed with the earthy phosphates in 
the sediment. 



EARTHY PHOSPHATES. Ill 



(b) Crystallized Calcium Phosphate. 

This substance (P0 4 HCa+2H 2 0) is found in pale, 
faintly acid urine which has a tendency to alkaline 
fermentation, and is usually very rich in calcium 
phosphate. 

The sediment seems to occur as a result of indi- 
vidual predisposition. Persons, otherwise perfectly 
healthy, are observed, whose urine always contains 
this sediment in summer. 

Under the microscope, either single, wedge-shaped 
crystals are found, or various arrangements of them ; 
several of them lying together, or having their apices 
directed towards one point, or in the form of rosettes, 
with the bases of the crystals forming the periphery 
of the rosette. The form of the crystal is so charac- 
teristic that error is hardly possible. 

The triple phosphate never forms rosettes, and uric 
acid can always be distinguished by its color and in- 
solubility in acetic acid. 

IX. Magnesium Phosphate. 

In neutral or faintly alkaline urine, long quadri- 
lateral plates, with rounded ends [basic magnesium 
phosphate (probably Mg 3 (P0 4 ) 2 -f-17H 2 0)] are occa- 
sionally observed. Especially is this the case after the 
internal administration of carbonates, or mineral 
water containing them. If a drop of a solution of 
ammonium carbonate (in five parts of water) is added, 
these plates become opaque and rough, and their 



112 



EXAMINATION OF THE URINE. 



corners fade. Calcium phosphate is affected much 
more slowly, and does not become opaque, and the 
triple phosphate shows no change, whatever, with this 
test. 

This sediment is very rare, and can only develop in 
highly concentrated urine which was originally of a 
neutral or alkaline reaction. If the alkalinity is 
caused by alkaline reaction, no magnesium phosphate 
can be formed, ammonium magnesium- phosphate be- 
ing the invariable result. 

X. Triple Phosphate. 

This substance is immediately recognized by its 
large, transparent Figp 8e 

crystals, which 
refract the light 
very much, and 
have well-devel- 
oped surfaces and 
angles. Among 
the many combi- 
nations of the 
rhombic form, 
hemimorp hous, 
the coffin lid, is 
frequently best 
known. The only 
conceivable m i s- 

, -i i -i 1 Triple Phosphate. 

take to be made, 

is between common salt, calcium oxalate, and this 

crystal. Common salt is never found in natural urine, 




CALCIUM CARBONATE. 113 

only in that which has been concentrated by evapo- 
ration. The reaction with acetic acid prevents any 
error in diagnosis regarding the larger crystals of 
calcium oxalate; the triple phosphate always disap- 
pears upon the addition of this reagent. The condi- 
tions producing the appearance of triple phosphate 
are the same as those discussed under the head of 
earthy phosphates. 

XI. Calcium Carbonate. 

Urine of most of the herbivora is turbid when 
voided, depending upon the separation of calcium 
carbonate. This condition is only exceptionally found 
in the human being, where the sediment usually 
forms some time after the urine has been passed. 

The causes for this phenomenon are obscure. 

It is probable that the sediment never occurs alone, 
but that it is mixed with earthy phosphates. It com- 
monly forms a coarsely granular or fine powder; 
occasionally it forms dumb-bell crystals; this, however, 
is exceptional. It is recognized by its effervescence 
and solubility upon the addition of mineral acids, 
which can be observed under the microscope. 

If a drop of hydrochloric acid is allowed to flow 
under the covering glass, small bubbles of gas (car- 
bonic acid gas) will be seen to escape. This never 
occurs when earthy phosphates alone are present. Be- 
fore making this test, the sediment must be carefully 
washed on a filter, to remove the ammonium carbon- 
ate, which would show the same reaction as the sub- 
stance tested for, 
e. u.— 9 



114 EXAMINATION OF THE URINE. 

Organized Sediments. 
I. Mucus. 

Great quantities of mucus may be present in urine 
without being easily detected, on account of the simi- 
larity that exists between its index of refraction, and 
that of urine. Mucus can only be seen in the form of 
the nubecula already described, after the urine has been 
allowed to stand for some time; when a great and 
rapid development of bacteria has taken place, and 
when an abnormally great quantity of epithelium is 
present. When these conditions are not present, it is 
necessary to color the urine. 

If albumin is absent, the mucus can be precipitated 
by alcohol which has tincture of iodine in it, or by 
acetic acid to which a solution of iodine in potassium 
iodide has been added. Acetic acid produces a tur- 
bidity in solutions of mucin, which is not dissolved 
by excess of acid, but which disappears when a few 
drops of hydrochloric acid are added. If the turbidity 
disappears upon heating, it was due to the urates, and 
not to mucus. 

Mucus does not show aiiy characteristic appearance 
under the microscope, but small bodies are found sus- 
pended in it ; crystals of oxalate of lime and uric acid, 
mucus corpuscles (young cells), or epithelial cells of 
the bladder. Mucus which has been coagulated by 
acetic acid shows a finely granular, striped mass, which 
sometimes resembles casts. 

In women the nubecula is usually larger than in 






EPITHELIUM. 115 

men, because more or less mucus is always present, 
from the vagina, especially in leucorrhoea. 

As mucin swells up, instead of dissolving, in water, 
it can be separated from the urine by filtration. It 
remains on the filter, and when dry looks like a var- 
nish. 

Urine which contains much mucus is not easily 
filtered, because the mucus fills up the pores of the 
paper. 

II. Epithelium. 

Besides the mucus corpuscles which are found sus- 
pended in mucus, we also find in urine, cells of another 
description; cells which formerly lined the urinary 
apparatus, or formed part of the glandular substance 
of the kidneys. The forms of these cells are less mani- 
fold when in urine than when taken directly from the 
organs of the cadaver, because the urine alters their 
shape. 

The forms of the cells may be divided into three 
classes : 

1. Round cells. 

2. Conical cells and cells with processes. 

3. Flat cells. 

1. The round cells come from the uriniferous 
tubules and the deeper layers of the membrane lining 
the pelvis of the kidney. In the beginning, they are 
more or less flattened, depending upon the manner in 
which they were originally arranged. Influenced by 
the urine, they swell up and represent spheres. They 
have a well-developed nucleus, and by it are differ- 



116 



EXAMINATION OF THE URINE. 




ontiated from pus, Fig. 9. 

whose cells are 
granular, and only- 
show a nucleus 
upon the addition 
of acetic acid. 
Epithelial cells 
have but one nu- 
cleus, pus cells 
have two or three, 
rarely more, and 
epithelial cells are 
the larger. 

In acid urine, 
epithelial cells are 

rvrpQPrv-Arl fnr cnmp vagina; c, from the prostate gland ; d, t 
pivhvi \ eu 101 home , g glands . e> from L ittre's glands ; /, 

time but when * emale urethra ; g, from the bladder. 

the urine becomes neutral or alkaline they appear 
larger, nearly hyaline (the granular protoplasm col- 
lecting around the excentric nucleus), and are finally 
completely dissolved. 

The epithelium of the male urethra can not be 
easily distinguished from that of the kidney, by the 
microscope. The chemical reaction of the urine must 
here be taken into consideration. If the urine con- 
tains albumin, the cells originate in desquamation in 
the uriniferous tubules; this not being present, the 
cells are, in all probability, from the urethra. 

Cells from the prostate, Cowper's and Littre's glands, 
are like those of the urethra, and can not be distin- 
guished from them by means of the microscope ; in all 



a, Epithelia from male urethra; b, from the 

d, from Cow- 
from the 



EPITHELIUM. 117 

probability they occur rarely in the urine. Fused 
with mucus and pus, they form the shreds found in 
gonorrhoea. 

The conical cells and cells with processes, in the 
majority of cases, come from the pelvis of the kidney; 
very fine and delicate cylindrical cells may be from 
the accessory organs of the male urinary apparatus, 
but these are quite rare. They are commonly twice 
as long as they are broad, and tapering towards one 
extremity. The second variety may have either one 
Dr two processes (unipolar and bipolar cells). The 
occurrence of these must not be considered as a symp- 
tom of noeplasmata, as is laid down in many of the 
older text books. 

3. Flat cells either originate in the bladder or in 
the vagina. 

As the name indicates, their form is flattened. 
Usually, they are irregular, polygonal, having rounded 
edges and a dark, sharply-defined nucleus, which is 
nearly central. The latter protrudes somewhat, and 
a cell of this sort, when seen in profile, appears thicker 
in the middle, like a spindle-shaped cell. 

It is only with difficulty that epithelium of the 
bladder can always be distinguished from epithelium 
of the vagina. The cells from the bladder are more 
delicate, and usually are found singly; those from the 
vagina are tougher — sometimes seem like scales; 
nearly always in larger or smaller flakes, above all, in 
layers, something which can not occur with epithelium 
of the bladder. 

Yellow discoloration of the nuclei of various <pi- 



118 EXAMINATION OF THE URINE. 

thelial cells in jaundice, is of interest. If a drop of 
fuming nitric acid is allowed to flow slowly under 
the thin covering glass, the well-known play of colors 
of Gmelin's test (green, blue, violet,) is produced 
(Ultzmann). 

III. Pus Corpuscles. 

Pus corpuscles in urine have the same microscopical 
characteristics that are possessed by those from a sup- 
purating wound. They are round cells, twice the size 
of red blood corpuscles, and have a granular exterior, 
which covers over, and hides, the nuclei which will 
immediately appear, however, on the addition of acetic 
acid. The granular appearance will then disappear, 
the corpuscles swell, and the multiple central nuclei 
become visible. 

One form, more rarely found, differs from these; its 
corpuscles, instead of being round, have many pro- 
cesses, and resemble the amoeba. 

Pus corpuscles undergo especial changes in alkaline 
urine; these are due to the action of ammonium car- 
bonate, which fuses, melts them together, when the 
microscope reveals an homogeneous mass with nuclei. 
Such pus forms an adherent, vitreous mass, which can 
only be poured out, as a whole, somewhat like the 
white of egg. 

Especial attention must be called to the fact that 
these masses are neither albumin nor mucus. The 
former never forms a sediment, and the latter never 
forms adherent masses. When pus is present, pus- 
serum must also be, and, therefore, albumin. In 






EPITHELIUM. 119 

every case, then, the albumin test discovers albumin, 
which is not the case with mucus. 

The number of pus corpuscles varies very much. In 
some urine so few are found that they are not detected 
by the naked eye; in others, they are so numerous 
that a yellowish or grayish-white precipitate of the 
height of a finger is found. 

In acid urine it is possible to confound the urates 
with pus; in alkaline, the phosphates. The former 
have already been differentiated in another place. 
The phosphates disappear upon the addition of a few 
drops of acetic acid, pus does not. 

But we have a positive test, without using the micro- 
scope, for pus — Donne's. 

Pour the urine from the sediment ; add to the latter 
a piece of caustic potassa or soda, and stir with a glass 
rod. If the sediment consists of pus it will lose its 
white color, will become green and vitreous, denser 
and, finally, be reduced to an adherent mass, i. e. 3 it 
assumes the appearance of pus in ammoniacal urine. 
As there exists in urine no other body which produces 
this reaction, the test is a positive one, only that when 
the quantity is small, the sediment will disappear, and 
in its stead a mucilaginous fluid will appear, but no 
mass. 

We not infrequently find in the sediment pus cor- 
puscles which have been destroyed (detritus), blood 
corpuscles, epithelium, etc. 



120 



EXAMINATION OF THE URINE. 



IV. Blood Corpuscles. 



The presence of blood corpuscles, even in small 
numbers, can easily be detected by the microscope. 

When urine, which is suspected of containing blood- 
coloring matter, or blood corpuscles, appears of a 
brownish-red tint, it must be allowed to stand for 
some time in order to permit the light corpuscles to 
come down as a beautiful red sediment (frequently 
only a trace). 

In acid urine, the corpuscles retain their shape 
a long time, represented by small discs possessing 
shading which corresponds to a central depression. 
If seen in profile Fig. io. 

they appear bi- 
concave. They 
are always sepa- 
rate (except in ex- 
cessive hemor- 
rhage from the 
bladder), when 
they are arranged 
in money-roll 
order and appear 
reddish, slightly 
tinned with green. 

This original 

IOrm IS Subjected blood Corpuscles.— To the right and above- 
to rnanv phano-PQ red corpuscles acted upon by diluted urine ; to 
to many cnangeb, the left> acted upon Dy salts . in the middle, the 

according* to the crenate form 5 ancl below, the normal. 

fluid in which the blood corpuscles are found. If the 




BLOOD CORPUSCLES. 121 

urine is very much diluted, especially when beginning 
to be alkaline, they swell up. The depression disap- 
pears, the blood corpuscle becomes spherical and seems 
smaller than before. The shading in the center dis- 
appears with the depression, but appears at the peri- 
phery, ^by which it is recognized as a sphere. 

When acted upon further, the corpuscle becomes less 
distinct, appears as a small bubble, then as a mere 
shadow, and, finally, disappears altogether. 

By the action of salts, blood corpuscles become smaller 
and crenate. The latter form is sometimes found in 
urine, by the side of the normal. They seem to be 
produced by small crystals whose corners lift up the 
surface of the blood corpuscle. Instead of being round, 
the corpuscles are sometimes oval, varying in size, and 
twisted into the form of a cup. 

In haematuria, accompanying parenchymatous dis- 
eases of the kidney and bladder, we almost always 
find spherical corpuscles of varying size. Very small, 
even dust-form corpuscles (mycrocytes) are found in 
these cases by the side of normal and large forms 
(macrocytes). 

When blood corpuscles are present, even in very 
small quantity, albumin can always be detected. 

If the corpuscles are dissolved by alkaline urine, the 
blood-coloring matter (haemo-and methaemo-globin) 
can be detected by methods elsewhere described. 

The etiologv of bloody urine will be discussed in 
Chapter VIIL 



122 EXAMINATION OF THE URINE. 

V. Casts. 

These structures are of the greatest importance for 
the diagnosis of kidney disease; because of their form, 
which discloses their origin — the uriniferous tubules — 
they are called casts. • 

In searching for them, great caution must be ob- 
served to avoid overlooking them. Their low specific 
gravity causes them to remain long-suspended in the 
urine, and, further, they only appear in urine which 
contains albumin, in which all suspended matter will 
settle slowly. 

The urine must first be allowed to stand for several 
hours, then carefully decanted, and the remainder 
poured into a wine-glass and allowed to stand for one 
or two hours. The last drops of the sediment are put 
under the microscope for examination. 

One must not be satisfied wdth one preparation, as it 
is frequently necessary to examine several, otherwise 
the casts elude discovery. On the other hand, one 
must guard against mistaking other structures for 
casts. Beginners are apt to consider every cylindrical 
arrangement of phosphates or urates, especially when 
deposited in mucus, as finely granular casts. 

Casts are usually accompanied by albuminaria, but 
just as we find cases in which albumin exists without 
the casts, so do we find casts without albumin. 

Examples of the first anomaly are found in albu- 
minuria of interstitial nephritis, in the amyloid and 
the hyperaemic kidney; the latter may occur in any 
serious inflammatory process, in which the casts may 



CASTS. 



123 



precede the presence of albumin by from twelve to 
twenty-four hours. 

Amongst the many varieties of casts, the following 
may be considered typical forms: 1, the coarse fibrin 
cast; 2, the finely granular cast; 3, the hyaline cast; 
4, the epithelial cast; 5, the so-called uric acid cast; 
6, casts of bacteria and cocci. 

1. Coarse Fibrin Cast* are roller-like, coarse, fre- 
quently corkscrew fis:. ii. 
coagula, with 
sharp outlines, 
and of yellowish 
or brow 7 nish - yel- 
low r color. Their 
diameter, greater 
than that of any 
other cast, indi- 
cates that they are 
formed in the low 7 - 
est part of the col- 
lecting tubule, 
near its opening 
into the papilla. 
Not infrequently casts - 
epithelial cells adhere to them. Bloody casts may be 
considered as a variety of this form, consisting of 
coagulated blood from rupture of the glomeruli. They 
are always dark brown, and, in some cases, seem to. 
consist entirely of blood corpuscles; in other cases, we 
observe in one part of the cast coagulated fibrin only, 
and in the other, only blood corpuscles. This form is 




Casts. — a, Finely granular ; b, waxy; 



blood- 



124 EXAMINATION OF THE URINE. 

always accompanied by blood corpuscles in the sedi- 
ment. (See Fig. 11, c). 

2. Finely Granular Casts (Fig. 11, a) are more deli- 
cate than those described above. They, apparently, 
are derived from the smaller tubules. They possess 
distinct contours, and, as their name implies, are finely 
granular throughout their whole extent. They are 
straight and tapering, either at one or both ends. 
Their diameter is the same throughout, narrowed at 
one point. In their granular structure, also, many 
modifications are observed. In places they are coarsely 
granular, in others this appearance is nearly lost so 
that they approach the hyaline casts, to be described 
presently (half-granular casts). Sometimes distinct 
fat globules are present. The addition of acetic acid, 
in some cases, causes a decided clearing up; in others, 
no effect at all is produced. The color of these casts 
is a faint grayish yellow. 

Both forms retain their shape for a long time in acid 
urine, losing it gradually in alkaline urine. 

3. The Hyaline Cast (Fig. 12, b) is partly of the size 
of the granular casts, partly, much smaller. They are 
either perfectly straight, frequently of considerable 
length, or curved. Whilst some give the impression 
of a solid, others seem like tubes with very delicate 
walls ; the one being decidedly cylindrical, the other, 
tape-like. 

Spiral casts, with one or more turns, are not infre- 
quently found. With the larger of these, distinct out" 
lines can be traced, but the smaller ones look shadowy 
under the microscope, and can only be separated from 



CASTS. 



125 



Fig. 12. 






their surroundings with difficulty. In such cases, it 
is advisable to add a few drops of a solution of iodine 
in iodine of potas- 
sium or aniline 
violet, to bring out 
the outlines. This 
causes the casts to 
turn yellow T ish (or 
bluish-violet), 
when they can be 
easily distin- 
guished. They 
show no signs of 
•granulation, but 
are pellucid and 
hyaline. 

lne Size 01 trie casts.— a, Uric-acid casts; b, hvaline; x c, epi- 

tape-like casts jus- thelial cast - 

titles us in the conclusion that they originate in the 
finest ramifications of the uriniferous tubules, perhaps, 
from the ascending limb of Henle's loop. 

Hyaline casts disappear very rapidly in alkaline 
urine. 

4. Waxy Casts (Fig. 11, 6) are generally of the same 
breadth as the granular casts; they are perfectly vit- 
reous, refracting light to such an extent that their 
outlines stand out somewhat like crystals of the 
triple phosphate, or similar clear crystals. They are 
straight, with sharply-broken, or tortuous ends. Their 
surface is sometimes wavy, as if the cast were made 
up of masses of colloid substance, which had become 




126 EXAMINATION OF THE URINE. 

fused. In places a distinct cleavage is noticeable, 
which gives the impression of a gelatinous mass, which 
had been compressed and has given away. They show 
the amyloid reaction, and possess greater resistance 
than other casts. This form is very rare, and has been 
found only in amyloid degeneration and tuberculosis 
of the kidney. 

5. Epithelial Tubes and Casts (Fig. 12, c). — There are 
processes in which the epithelial lining is stripped, in 
toto, from the membrana propria of the tubules, and 
is washed out of them on account of the vis a tergo of 
the urine, or of a fluid exudation. 

Such casts, made up of epithelial cells, are hollow, 
and are called tu^es. 

Casts, covered with epithelial cells, as with the finger 
of a glove, are found in the same sediment, from which 
the hollow tubes may be absent. These cells are 
always cloudy, sonlewhat swollen, and are rarely pos- 
sessed of sharp outlines. They are frequently so much 
enlarged as to look more like a finely-granular mass, 
but the nuclei, which are present at regular intervals, 
betray the cell formation. 

Amongst epithelial casts some are found, in which 
the epithelial layer is wanting in places, and the con- 
gealed exudation can be seen ; and others, in which 
the central exudation protrudes beyond the epithe- 
lium. 

6. Uric Acid Casts (Fig. 12, a) differ greatly from the 
preceding ones, as regards structure, and can be classed 
with them, only because of their common origin. 
They are most commonly found during the first days 



CASTS. 127 

of life in children suffering from uric acid infarction. 
Small red bodies can be observed in the urine, as 
well as in the liver, of such patients, which show a 
cylindrical structure under the microscope. They are 
not made up of pure uric acid, as the name would lead 
us to suppose, but balls of urates. In color they are 
brownish-red ; in structure, decidedly granular, and in 
size they vary greatly. Treated with potassium hy- 
drate, ammonia escapes, and the casts disappear. 
Parts of casts are also found. 

7. Casts made up of Bacteria and Cocci occur only in 
suppurating interstitial nephritis, and not then, unless 
the disease is complicated with emboli of bacteria in 
.the uriniferous tubules (Nephritis Parasitica — Klebs). 

These casts are similar to the large fibrin casts in 
shape and size. They come from the collecting tubules, 
and are sometimes dichotomously divided, showing 
that they originate where two large tubes unite. They 
are made up entirely of cocci and bacteria. On account 
of the bacteria being at perfect rest, the casts resemble 
the coarse granular ones, but high powers make mis- 
take impossible. 

Several forms mentioned in other text-books are 
not given here; because having failed to observe them 
ourselves, we conclude that they must be exceedingly 
rare. We refer here to casts of pus cells, which must 
not be mistaken for those short plugs which close up 
the mouths of tubules at the papilla, and are charac- 
teristic of chronic pyelitis; furthermore, casts, com- 
posed of calcium oxalate, and casts that have uric acid 
imbedded in them. It is very common to find casts 



128 EXAMINATION OF THE URINE. 

that have calcium oxalate or uric acid adhering to 
them, but these are not imbedded in the cast, and 
have, consequently, been accumulated outside of the 
uriniferous tubule. 

IX. Fungi. 

Fungi, in different stages of development, are found 
in urine; some are frequently met with, whilst others 
are merely accidental admixtures. 

The forms which are most commonly seen are: 1. 
Bacteria. 2. Yeast Fungus. 3. Sarcinae. 4. O'idium 
lactis. 5. Spores and fragments of penicillium glau- 
cum. 

1. Bacteria are found principally in alkaline urine. 
Writers have differed as to their character, some classi- 
fying them as vegetables, others considering them ani- 
mals; hence the difference in their names — vibriones, 
monas crepusculum, microzyma, etc. It now seems 
settled that they must be considered as fungi belong- 
ing to Nageli's schyzomycetes. They vary so much 
in appearance, that it seems practical to give different 
names to the different forms, according to A. Vogel, 
but it must always be borne in mind that it is merely 
different forms of one and the same fungus. 

(a) The Monad. — Round, punctiform bacteria, either 
at rest or vibrating. Care must be taken not to take 
earthy phosphates having molecular motion for these 
fungi. Granules of a dead body have motion, but do 
not change their place in the field like the bacteria. 

(b) The Rod.— Very small rods, hardly as long as 



FUNGI. 



129 



the diameter of a red blood corpuscle, whose thickness 
is too small for measurement. Both extremities are 
somewhat dilated. They are at rest or in motion. 

(c) The Leptothrix, or Chain Form, are long chains, 
frequently extending over the whole field, and can be 
distinguished from vibriones by their length. With 
high powers their structure can be observed. They 
rarely move, and then very slowly. 

(b) The Vibrio, originating in the former. Several 
rod-bacteria adhere to each other, and either move in 
a spiral direction, or the members at the ends vibrate 
like the tail of a fish. They frequently move with 
great rapidity. Fig. 13. 

(e) The Zooglea 
Form. — Masses of 
punctiform bac- 
teria, held together 
by a gelatinous 
mass, and looking 
like a mass of 
earthy phosphates 
imbedded in mu- 
cus. 

All these forms 
can be observed in 




Fungi.— a, Micrococci and vibriones; b, Sar- 
cinae : c, Saccharomvces urinae ; rf, Yeast-fungus ; 
e, Penicillium glaucum. 



one urine, even in 
one preparation. 

2. The Yeast 
Fungus — Saccharomyces Urinae. — Single, vesicular cells, 
of the size of red corpuscles, somewhat oval. Com- 
monly arranged in a beaded form, or as one large cell 
e. u.-io 



130 EXAMINATION OF THE URINE. 

having several smaller ones resting upon it. Their 
number is usually much smaller than that of bacteria; 
they are found principally in acid urine, and in warm 
weather this fungus is very like the yeast fungus of 
beer (saccharomyces cerevisiae), without being ident- 
ical with it. In the urine of diabetes, the same form, 
better developed, is found. 

3. Sarcina. — This fungus resembles the sarcina 
ventriculi, but is much smaller. It is arranged in 
groups of two, four, eight, etc., cells, which look very 
much like bales of goods, where they are collected in 
the form of cubes. 

Urine which contains this form of fungus is usually 
alkaline, consequently, calcium phosphate and the 
triple phosphate are found in connection with it. The 
sarcinae usually appear for weeks, even for months, 
in the urine of the same patient. 

4. O'idium Lactis. — Long cells, to be recognized by 
their nuclei placed in rows at regular intervals. This 
form is not uncommon in fermenting diabetic urine. 
Besides the forms already mentioned, we find in urine 
sporules of 

5. Penicillium Glaucum, partly engaged in segmen- 
tation. They are sometimes mixed with fine urates, 
which causes them to appear brownish-red, and fur- 
like ; or where they have developed further, we find a 
network of fine thallus threads. 

The seeds for the development of these forms, as a 
rule, are mixed with the urine outside of the bladder. 
Like other rules, this has its exceptions. The sarcina 
is voided with the urine; this is also the case, some- 



SPERMATOZOA. 131 

times, with bacteria, but the cause is to be found in 
unclean catheters and sounds. We have rarely met 
with cases of bacteria in the urine in which an instru- 
ment had not been introduced into the urethra or 
bladder. 

Whether these structures play a role in fermenta- 
tion and the reaction of urine, is very doubtful. The 
small chains appear, not only in alkaline urine, but 
wherever albuminous substances undergo decomposi- 
tion. We find them, therefore, in secretions from a 
variety of ulcers, in bad pus, in passages from cholera 
patients, etc. 

A membrane named kyesteine, made up of fungi, 
calcium phosphate, triple phosphates, and sometimes 
animal organisms, was formerly held to be character- 
istic of the urine of pregnant women. This, being 
also found upon the urine of males, is of no value as 
a sign of pregnancy. 

VI. Spermatozoa. 

Spermatozoa, when viewed with a high power, have 
the appearance of small spherical structures, with a 
hair-like tail. In urine, they are seldom found in 
motion. Urine containing sperm frequently show r s 
small, cloud-like bodies, which, under the microscope, 
are seen to consist of spermatozoa imbedded in a 
finely granular mass. The spermatozoa are very light, 
and therefore require from six to twelve hours before 
they are found in the sediment. They may be found 



132 



EXAMINATION OF THE URINE. 



several days after the urine has been passed, and 
under the following conditions : 

1. After coitus, nocturnal emissions, etc., when 
semen has remained in the urethra, and been washed 
out by the urine. 

2. Spermatorrhoea ; in grave attacks of typhus, in- 
voluntary passages of semen have been observed. 

Spermatozoa are found in the urine of women after 
coitus, and may be of medico-legal importance. 

VII. Histological Elements of Cancer. 



Two forms of cancer elements are observed, both 
very rarely, however, (a) Single cancer cells; (b) Pieces 
of cancer tissue, (a) Fj |4 

The cells vary; 
frequently of un- 
common shape, 
large, caudate, with 
multiple nuclei. 
So-called nests are 
sometimes met 
with. We must 
avoid mistaking 
caudate cells from 
the kidney (pel- 
vis) for cancer 
cells. The cells 
correspond to the 
epithelial cover- 
ing of the cancer granulations, and commonly origi- 




Cancer Tissue and Cells. 



HISTOLOGICAL ELEMENTS OF CANCER. 133 

nate in the bladder. We are justified in making a 
probable diagnosis only when these peculiar cells are 
present in great quantity. 

(b) The Stroma of the Papillary Cancer occurs in 
various forms in the sediment. Either it is well pre- 
served, which occurs rarely, and makes the diagnosis 
easy, or it is necrotic, when the diagnosis of these 
papillary proliferations is exceedingly difficult. 

When well preserved, the villous tissue presents, in 
its finest sub-divisions, dentritic structures resembling 
fingers, easily studied w r ith a power of three hundred 
diameters. These consist in an ecstatic blood-vessel, 
which is usually covered by one layer, only, of epi- 
thelium. This, however, is a rare picture, and the 
dead modified papillae are more commonly found, 
whose diagnosis is exceedingly difficult. In these, the 
dentritic form can no longer be verified, the epithelial 
covering has been destroyed, and the papilla, itself, 
infiltrated with pus corpuscles. In this formless mass, 
however, structures are occasionally found that make 
the diagnosis much easier. They are : 

Beautiful crystals of haematoidin, w r hen the necrotic 
tissue is treated with glycerine. They are of a 
yellowish-brown color, and appear either in the form 
of rhombs or bundles. Under the" microscope, this 
tissue gives the characteristic reaction for bile color- 
ing matter, when treated with fuming nitric acid. 
Haematoidin only occurs in old extravasations of 
blood ; it is never found in urine as a sediment in its 
isolated crystalline form. But if we find these crystals 
imbedded in necrotic tissue, the diagnosis of old 



134 EXAMINATION OF THE URINE. 

necrotic and hemorrhagic tissue is a positive one, and 
this latter has been found only in papillary tumor of 
the bladder. The haematoidin villus can be found 
only in acid urine. 

Another form of crystal, which we have found only 
in necrotic cancer tissue, and only in acid urine, is a 
rare form of calcium oxalate, small, colorless, aggre- 
gated, flaky crystals, in the form of dumb-bells cross- 
ing each other, and sometimes presenting a spherical 
form. 

With low powers, we occasionally find in one of 
these flocculi, dense, dark, tubular, branched struct- 
ures. These are the minute blood-vessels, which are 
still to be seen in the villus. 

When the urine is highly alkaline, the papillae may 
be covered with phosphates, and so changed that a 
diagnosis is next to impossible. One examination 
does not suffice for a recognition of this disease. 

VIII. Entozoa. 

Thus far, we have never found parts of entozoa in 
urine. According to other authors, the hooklets of 
echinococci occur in the sediment. We have, how- 
ever, observed hooklets, as well as a piece of an echin- 
ococcus-sac with the animals, in fluid drawn from a 
tumor of the kidney, and it is possible that hooklets 
are found in the urine when such a tumor breaks into 
the pelvis of the kidney. 

Haematuria, produced by entozoa, is frequently ob- 
served in the tropics. The entozoon which has the 



CONCRETIONS. 135 

most importance in this respect, is the distoma haema- 
tobium, or the bilharzia haematobia, which probably 
migrates from the intestine into the venous plexus of 
the prostate gland, where it lays its eggs. These are 
of oval form, with a sting-like process at one end. 
They plug up the smaller vessels of the bladder, 
catarrh with hemorrhage is produced, and the eggs 
are discharged with the urine. 

The fact that a great many accidental impurities, 
which have no relation to the urinary apparatus, may 
be found in urine, is hardly worth mentioning ; pieces 
of feathers, of wood-cells, of plant parenchyma (tobacco 
leaves, for instance), dust, very fine fibres of cotton, 
silk, etc. Neither is it necessary to mention that care 
must be taken to avoid mistaking substances on the 
slide or its thin cover, or air bubbles, for sediments. 

Addendum. 
Concretions. 

By concretions we mean hard, stony bodies, made 
up either of normal or abnormal constituents of 
urine. These vary greatly in size, from such as can 
hardly be discovered through the microscope, to some 
which are as large, or larger, than the fist. 

Every concretion, whatever its size, will show a 
deposit of molecules in layers, and must, of necessity, 
be more or less rounded. The cystin calculus, which, 
upon section, shows a crystalline structure, is the only 
exception to this rule. In order to convince ourselves 



136 EXAMINATION OF THE URINE. 

upon this point, either a lense or a microscope must 
be called into requisition. Concretions of uric acid 
are frequently found which, with the naked eye, might 
easily be mistaken for a conglomerate of uric acid 
crystals (rosette). Concretions of calcium carbonate are 
also found, whose arrangement in layers is only visible 
when a powder of 100 or 200 diameters is used. 

Small concretions usually come from the kidney. 
Larger ones, from the bladder. 

Calculi are made up either of one constituent solely, 
or of several, arranged in layers. Thus, uric acid 
calculi usually consist, throughout, of uric acid or its 
salts ; cystin calculi of cystin ; while the oxalates fre- 
quently have a nucleus of uric acid and an outer 
layer of phosphates ; and the phosphates, a nucleus of 
uric acid. 

It is immaterial w T hether one or more substances 
are used for the formation of the calculus; we are 
always in a position to distinguish the nucleus. 

In order to examine the structure of the calculus, it 
is necessary to cut it by means of a fine watchmaker's 
saw. The innermost layer is the nucleus, which 
varies in size from a millet seed to that of a pea, or 
over, and shows to greatest advantage when sur- 
rounded by a layer of structures different from its 
own. 

The nucleus is the most important part of the cal- 
culus, as it alone gives definite knowledge regarding 
the genesis of the stone. If we find an uric acid 
nucleus in a phosphatic calculus, we will know that 
calculus formation was caused bv uric acid; if we find 



CONCRETIONS. 137 

a foreign body, as a piece of catheter or bougie, we 
may know that this was the primary cause. 

From a surgical stand-point, calculi are divided ac- 
cording to their principal constituent ; thus, calculi of 
urates, oxalates, phosphates and cystin. This division 
is of great practical importance, for, if a surgeon states 
that a calculus is phosphatic, he, at the same time, 
implies" that it is soft; if oxalate or urate, that it is 
hard. 

But as calculi exist that are made up of three or 
more calculus-forming substances, it might embarrass 
the surgeon to say to which group they belong; it is 
better, therefore, to divide all calculi into two groups, 
characterized by their nuclei. 

One group contains all those calculi w T hose nuclei 
are formed by the sediments of acid urine; the second, 
those whose nuclei are either foreign bodies, coagula 
of blood, or constituents of alkaline urine. 

This division agrees with what is known as primary 
and secondary calculus-formation; primary being the 
first, and secondary, the second group, to w T hich latter 
is added the incrustation of a calculus from the kid- 
ney, in the bladder. Primary calculus-formation takes 
place only in the kidney ; secondary, almost always, in 
the bladder. 

A separate class is formed by the so-called metamor- 
phous calculi, which consist of earthy phosphates, and 
form a homogeneous, porous mass. These are always 
the result of a purulent process, of years continuance, 
in which the sediment of acid urine has been dissolved 
by alkaline pus, and substituted by the earthy phos- 
phates. 



138 EXAMINATION OF THE URINE. 

Primary formation is principally begun by uric 
acid, the majority of calculi of the bladder having a 
nucleus of it. 

In 545 calculi from the bladder, Ultzmann has 
found the nucleus to have the following composition : 

Uric Acid, 441 or 80.9% 

Calcium Oxalate, 31 or 5.6% 

Earthy Phosphates, 47 or 8.6% 

Cystin, 8 or 1.4% 

Foreign bodies, 18 or 3.3 % 

Analysis. 

Every calculus must be divided into two equal 
parts with a saw. The dust from the sawing must be 
mixed, collected, and examined by the key which 
follows. In this way all the principal constituents 
are discovered, but not their arrangements. 

In order to determine this, one-half is polished upon 
a glass plate until the various layers can be easily dis- 
tinguished. From each layer sufficient quantity is 
scraped off with a pen-knife, and this is examined 
separately. An illustration will make this clearer. 

It has been determined that the \ of a calculus is 
made up of f inorganic (non-combustible), and \ or- 
ganic substances. Furthermore, the following sub- 
stances have been detected: Uric acid, oxalic acid, 
phosphoric acid, calcium, magnesium and ammonium. 
On polishing, we now find three layers. The nucleus, 
by the proper test, is found to consist of uric acid ; the 
dark-brown middle layer, of calcium oxalate, and the 



ANALYSIS. 139 

white outer layer, of calcium carbonate and phos- 
phates, and magnesium. 

The method for analysis is as follows : 

A few millegrammes of the powder are heated to 
redness on platinum. In this test be careful to ob- 
serve whether or not a deposit is left after burning; 
whether or not a visible flame is produced ; whether 
the substance crackles (calcium oxalate), and whether 
it gives off a characteristic odor. 

I. When no deposit is left after burning, the follow- 
ing substances may be present : Uric acid, sodium and 
ammonium urates, xanthin, protein and cystin. 

1. Protein gives off, when burnt, a yellow, lumin- 
ous flame, and an odor like burnt feathers or hair. 

2. Cystin burns with a faint, bluish-white flame, 
and produces a penetrating odor, as of burning fat 
and sulphur. The powder is soluble in diluted am- 
monia, and upon evaporation shows the characteristic 
crystal. 

3. Xanthin, w T ith the murexid test, produces a 
pomgranate-yellow color, and burns without visible 
flame. 

4. Uric Acid, sodium urate and ammonium urate, 
give the characteristic murexid reaction. 

(a) Sodium Urate can be distinguished from the 
ammonium urate, and from uric acid, as follows : At 
the spot on , the platinum where the urate is burnt, a 
slight haziness remains ; a piece of red litmus paper, 
moistened, and put upon this spot, will turn blue im- 
mediately, wherever it touches the haziness. This 
reaction is probably due to the presence of sodium 



140 EXAMINATION OF THE URINE. 

carbonate or hydrate, formed by the decomposition of 
sodium urate. 

(6) Ammonium Urate can be distinguished by the 
detection of ammonium. Some of the powder is 
moistened by potassium hydrate, and a piece of red 
litmus paper, which the escaping ammonium will 
turn blue, is suspended over it. 

(c) Free Uric Acid gives negative results with both 
of these tests. 

II. When the powder burns incompletely, or not at 
all,*it consists chiefly of calcium and magnesium salts. 
The following are found in the form of calculi: 
Calcium oxalate, calcium carbonate, calcium phos- 
phate, and triple phosphates. 

1. Calcium Oxalate does not effervesce when hydro- 
chloric acid is added. When heated we notice a 
peculiar glowing, and a crackling sound. By heating, 
the oxalate is converted into a carbonate, and the 
addition of hydrochloric acid will cause a decided 
effervescence. 

2. Calcium Carbonate will effervesce without being 
heated, upon the addition of hydrochloric acid. 

3. Calcium Phosphate and the Triple Phosphate 
neither effervesce before or after heating, but hydro- 
chloric acid will entirely dissolve the powder after 
heating. If ammonium hydrate is added until the 
solution becomes alkaline, a flaky precipitate of amor- 
phous basic calcium phosphate, and crystalline triple 
phosphate, will be found. Under the microscope, the 
latter is shown to consist of crystals in the form of 
stars and crosses. 



REAGENTS AND APPARATUS. 141 



CHAPTER IV. 

Reagents and Apparatus for the Approximate 
Examination of the Constituents of Urine. 

It is best to have wide-necked bottles, with ground 
stoppers, holding 250 c. c. of fluid. We give the 
reagents in the form of prescriptions : 

(a) Acids. 

1. Acid, hydrochloric. C. P., 200.00. 

2. Acid, sulphuric. C. P., 200.00. 

3. Acid, nitric. C. P., 200.00. 

4. Acid, acetic. C. P., 200.00. 

(b) Bases and Salts. 

5. Potass, fus. pur., 100.00. 
Aquae destillat., 200.00. 

6. Ammon. pur. liquid, 100.00. 

7. Barii chlorid. cryst., 30.00. 
Aquae destillat., 200.00. 
Acid, hydrochloric, 10.00. 

8. Plumbi acetat, cryst., 30.00. 
Aquae desk, 200.00. 

9. Cupri sulphat., 30.00. 
Aquae destillat., 200.00. 

10. Magnesiae sulphat. 

Ammonii chlorid. pur. aa, 30.00. . 
Aquae destill., 200.00. 
Ammon. pur. liquid, 50.00. 

11. Argenti nitrat., 5.00. 
Aquae destill., 40.00. 

12. Red and blue litmus paper, cut in strips. 



142 EXAMINATION OF THE URINE. 

Besides these necessary reagents, it is also well to keep the 
following, for special cases: Distilled water, ferric chloride, 
zinc chloride, hasic lead acetate, mercuric nitrate, bismuth 
sub-nitrate, fuming nitric acid, potassium nitrite, starch, 
chloroform, ether, alcohol, iodine dissolved in potassium 
iodide, glacial acetic acid, sodium chloride, etc. 

Apparatus. 

1. Six test-tubes and stand. 

2. Ten wine glasses (such as are used for sherry wine). 

3. Cylinder glasses, with a capacity of 100, 200, and 300 c. c. 

4. A graduated cylinder. 

5. A flask with capacity of 100 c. c, with cork perforated 
by a glass tube. 

6. An urinometer (areometer). 

7. A spirit lamp. 

8. Two small porcelain dishes. 

9. A brass stand, with two rings. 

10. Filter paper. 

11. Four funnels. 

12. Glass rods. 

13. A microscope. 

14. A glass vessel, with capacity of 3,000-4,000 c. c. 
Watch glasses, beakers and pipettes. For quantitative pur- 
poses, apparatus for volumetric analysis are also needed. 



CHAPTER V. 

Quantitative Detection of Urinary Constituents. 

The one condition necessary for all quantitative 
estimations, is the exact collection of all the urine 
passed within a given time. It is usually collected 



ESTIMATION OF ACIDITY. 143 

during twenty-four hours, and in order to prevent its 
mixture with feces, it is passed before defacation. 

It is inadvisable to multiply the quantity for one hour, in 
order to estimate that of any number of hours, as the quantity 
of urine varies with different parts of the day. 

Urine is collected in graduated cylinders. In order 
to find the average of excretion of any patient, the 
urine for several successive twenty-four hours should 
be collected and averaged. 

I. Estimation of Acidity. 

To estimate the degree of acidity, a solution of 
sodium hydrate must be added, until neutral reaction 
sets in; then find out how much of any acid (best, 
oxalic acid) is required to neutralize the quantity of 
alkali used. 

(6) Test Solution. 

An T r o solution of sodium hydrate, which contains 0.0031 
grammes NaO in 1 c. c, is necessary to neutralize 6.3 mille- 
grammes of crystallized oxalic acid. 

(6) The Test 

Measure off 100 c. c. of urine in a beaker, then add, 
with a burette, the above solution until the reaction 
to litmus is negative. The number of c. c. used is 
multiplied by 0.0063. This product shows the acidity 
of 100 c. c. of urine reduced to oxalic acid. 



144 EXAMINATION OF THE URINE. 



II. Total Solids. 

Ten c. c. are evaporated to dryness, over a water bath, in a 
porcelain dish which has been weighed, this kept at 100° C. in 
the air-bath for an honr, then allowed to cool under a dessi- 
cator, and weighed. Again dried and dessicated and weighed, 
and this operation repeated until no diminution in weight is 
observed. The difference between this weight and that of the 
dish represents the weight of the solids in 10 c. c. of urine. 
Unfortunately, the result is not accurate on account of the 
reaction of the acid sodium phosphate upon urea, producing, 
at 100° C, carbonic acid gas and ammonia, which are lost. 

Usually the approximate means are sufficiently exact for 
the practicing physician. If not, the method of Neubauer 
ought to be used. (See Neubauer and Vogel, Analysis of 
Urine. 

III. Urea. 

1.— The Method of Liebig. 

(a) Reagents. 

1. Barium Solution. — One vol. of saturated (cold) solution of 
barium nitrate is mixed with 2 vol., cold, saturated solution 
of barium hydrate. 

2. Titrate for Urea, i. e., solution of pure mercuric nitrate, 
of the concentration that 71.48 gr. of pure mercury, or 77.2 gr. 
of mercuric nitrate; dried, at 100° C, are contained in 1 litre. 
(For preparation see Neubauer and Vogel.) 

Solution of Sodium Carbonate. — For Eaudenberg's modifica- 
tion, acid sodium carbonate must be used. This is stirred up 
in water, after having been rubbed up finely and washed by 
small quantities of water until turmeric is no longer turned 
brown. 



UREA. 145 



(6) The Test 

With a pipette, 40 e. c. of urine are taken, and 20 c. 
c. of the barium solution added. A precipitate of 
phosphates and sulphates will result. Allow this to 
stand, and then filter into a dry vessel through dry 
paper. The filtrate is composed of one-third barium 
solution, and two-thirds urine, from which the phos- 
phates and sulphates have been removed. Of this 
mixture, 15 c. c. are poured into a dry vessel (only 
two-thirds, or 10 c. c, are urine), and the solution of 
mercuric nitrate is allowed to flow into it from a 
burette. Having used as many c, c. of the solution as 
are indicated by the last two figures of the specific 
gravity of the urine examined (thus 13 c. c. if sp. gr. 
is 1.015), it is necessary to see whether or not the limit 
has been reached. 

Put a drop of the mixture into a porcelain dish, and 
add to it a drop of sodium carbonate. If a rusty zone 
is produced where the fluids meet, continue to add the 
test fluid: if this zone is pale, do not continue, for the 
work has been completed. 

The chemical process is as follows: On the addition of 
mercnric nitrate Hg(N0 3 ) 2 it first seeks the chlorine con- 
tained in the common salt in urine, forming HgCl 2 (corrosive 
sublimate). 

fN0 3 NaCl 
Hg + = HgCl 2 +2NaN0 3 

lN0 3 NaCl 

The NaN0 3 remains in solution, but the HgCl 2 is precipi- 
tated, the solution being alkaline. After all the XaCl has 

E. V.— 11 



\ 

146 EXAMINATION OF THE UEINE. 

been converted into HgCl 2 , the mercuric nitrate forms a com- 
bination with the urea, by which N0 3 is liberated, which 
upon the addition of sodium carbonate, takes the place of the 
carbonic acid, which escapes in fine bubbles. NaN0 3 does 
not change the color of the precipitate in the porcelain dish. 
But if the limit has been reached, where all the mercuric 
nitrate is bound to the urea, and a drop of the mixture with 
urine is added to sodium carbonate, mercuric oxide will be 
precipitated, at the same time NaN0 3 being formed, and C0 2 
escaping: 

Hg(N0 3 ) 2 +Na 2 C0 3 = HgO + C0 2 +2NaN0 3 . 

HgO is precipitated as a brownish powder, which, as we 
now comprehend, forms the limit test for the reaction. 

Having completed titration, the burette is allowed 
to stand for a few minutes, and we then read off how 
many c. c. have been used. 

The fluid is so arranged that 1 c. c. satisfies 10 millegrammes 
of urea, exactly. If we had used 20 c. c. t^iere would be 
present 200 mgr. of urea in the mixture (15 c. c), which was 
made up of 10 c. c. urine and 5 c. c. barium fluid. From this 
can be computed, without difficulty, how much urea is passed 
in twenty-four hours. 

1. As the test fluid is fixed for a 2% solution of urea, we 
can only obtain accurate results when for 15 c. c. of a 2<f 
solution of urea, there is used exactly 30 c. c. of the mercury 
solution, of which 1 c. c. represents 10 mgr. of urea, exactly. 

Every c. c. of the solution requires for the satisfaction of 10 
mgr. of urea, 72 mgr. HgO. In order, however,* to produce 
the terminal reaction, there must be an excess of HgO. Ac- 
cording to Liebig, this amounts to 5.2 mgr. for 1 c. c. of the 
solution, for 30 c. c. 30 X 5.2=- 156 mgr. If, now, to 15 c. c. of 
a 2<f solution of urea, 30 c. c. of the solution are added, the 
mixture amounts to 45 c. c, in which there are 156 mgr. of 



UREA. 147 

HgO in excess, i. e., 3.56 ingr. for each c. c. In order to effect 
a positive terminal reaction, then, it is necessary to have in 
each c. c. of mixture 3.46 mgr. of HgO in excess. 

If the 15 c. c. of urea solution have 3.5% urea, 52.5 c. c. of 
the mercury solution would be required. The quantity of the 
mixture then would be 15 c. c.-f 52.5 c. c. = 67.5 c. c; in the 
52.5 c. c. of solution is present 52.5X5.2= 273 mgr. of HgO in 
excess, in every c. c. of the mixture; therefore, 4.04 mgr. But 
the termination of the reaction takes place with 3.46 mgr., we 
therefore have 0.58 mgr. too much. In this way the terminal 
reaction sets in too early. 

If the solution only contains 1% of urea, the error would be 
in the other direction. 

In order to eliminate both errors, we proceed as follows: 

(a) If more than 30 c. c. of the test solution is required, add 
half as much water as the number of c. c. of test solution is 
more than 30 before testing with the sodium. Thus, as 52.5 c. 
c. have been used, we add *|- fi =ll c. c. of water to the mix- 
ture before testing with soda. 

(b) If less than 30 c. c. were sufficient, then we deduct for 
every 5 c. c. less than 30 c. c, 0.1 c. c. from the whole quantity 
used. Thus, if we use 20 c. c. (10 c. c. less) we compute with 
20— 0.2= 19.8 c. c. 

2. If the urine contains 1 — 1.5$, XaCl, the formation of 
corrosive sublimate will necessitate an increased amount of 
the test solution, which, without being corrected, would give 
too great an amount of urea (15 to 25 mgr.). In order to cor- 
rect this error, subtract 2 c. c. from the figures read off from 
the burette. 

If we wish to get absolutely correct results, we must either 
first titrate the XaCl with a nitrate of silver solution, or use 
Raudenberg's method. According to this, two tests are made, 
for each of which 15 c. c. of mixture are prepared. The one 
is acidulated with nitric acid, and the mercuric nitrate solu- 
tion is added until the cloudiness remains permanent. With 
the second test we proceed according to Liebig, with the 



148 EXAMINATION OF THE URINE. 

addition of keeping the mixture neutral by means of freshly 
precipitated calcium carbonate. For the terminal reaction, 
the solution 3 (sodium carbonate) is employed. We now sub- 
tract the c. c. used in the first test from the number used in 
the second, and from this we calculate the quantity of urea. 

3. If albumin is present, 20 c. c. are placed into a vessel 
that can be closed, a few drops of acetic acid added, and then 
boil until the albumin separates in coarse flakes; now close 
the vessel and allow to cool. Finally, filter, and proceed as 
before. 

II. Method of Bunsen (Bunge). 

Only to be used when neither sugar nor albumin are pres- 
ent. Fifty c. c. of urine are precipitated with an ammoniacal 
solution of barium chloride, filtered, and 15 c. c. of this put 
into a tube with thick walls. Upon the bottom of the tube 
are three grammes of crystallized barium chloride. Seal the 
tube and heat to 200° C. for six hours in an oil-bath. After 
cooling, break off the point of the tube, pour the contents 
upon a filter, wash out the barium carbonate that has col- 
lected, and dissolve it in a sufficient quantity of hydrochloric 
acid. Care must be taken to wash off and dissolve any 
barium carbonate that may be found adhering to the walls of 
the tube. All of the solution is filtered and precipitated with 
sulphuric acid, the precipitate of barium sulphate collected, 
washed, heated and weighed. 

Two hundred and thirty -three grammes of barium sulphate, 
representing 60 grammes of urea, we can easily compute the 
quantity of urea present. 

III. Method of Knop-Hufner. 

(a) Solutions. 

1. Hypobromite of Sodium. — One hundred grammes of 
sodium hydrate are dissolved in 250 c. c. of water, and mixed 



ESTIMATION OF URIC ACID. 149 

with 25 c. c. of bromine. This must always be prepared 
fresh. 

2. J. saturate solution of common salt. 

(b) Test. 

Dilute 10 e. c. of urine with 40 c. c. of w T ater, fill the lower 
cup, and the cork, of Hiifner's apparatus with urine, fill the 
upper part with the hypobromite solution, and the vessel 
above with the salt solution, and into it put the eudiometer. 
After five minutes the development of gas ceases. After one 
hour the eudiometer is taken off, and the quantity of urea is 
calculated, according to the method of Dumas, 1 gramme of 
urea producing 370 c. c. of nitrogen (at 0°C and 760 m.). 



IV. Estimation of Uric Acid. 

To 300 c. c. of urine are added 10 c. c. of hydro- 
chloric acid ; this is well stirred, and allow r ed to stand 
in a cool place for forty-eight hours. Albumin, if 
present, must be removed; if the urine contains sugar, 
it must be treated with mercuric acetate; the precipi- 
tate, being washed on a filter, is mixed with a little 
water; hydrogen di-sulphide is allowed to act on it, 
when it is again filtered. The mercuric sulphide is 
washed with warm water, and this water is treated 
like the urine. The crystals of uric acid are collected 
on a filter paper wdiich has been washed with water 
and acetic acid, dried between two watch-glasses at 
100° C, and then weighed. As uric acid crystals are 
very heavy, they can be collected by decanting the 
fluid; the crystals which adhere to the walls of the 
vessel can be removed with a feather, w T hen they will 



150 EXAMINATION OF THE URINE. 

'fall to the bottom. Only when the crystals are very 
small is it necessary to filter. 

Uric acid is washed with distilled water until the. 
filtrate no longer produces a reaction with silver 
nitrate. It is better to use not more than 30 c. c, 
otherwise some of the uric acid is dissolved. If more 
than 30 c. c. have been used, 0.045 mgr. for each c. c. 
of water used must be added to the whole amount of 
uric acid found. 

The uric acid is now dried at 100° C, between 
watch-glasses, in the air-bath, dried in the dessicator, 
and weighed. 

The difference between the two weighings represents 
the weight of uric acid contained in 300 c. c. of urine. 

Schwanert recommends adding for every 100 c. c. of urine 
employed, 0.0048 grammes, claiming that the result is more 
correct. 

V. Estimation of Creatinin. 

(a) Reagents. 

1. Zinc Chloride Solution. — Pure zinc oxide is dissolved in 
pure hydrochloric acid; this solution is evaporated in the 
water-bath to the consistency of syrup (until no free acid can 
be detected), dissolved in strong alcohol until specific gravity 
of 1,200 is reached. 

2. Milk of Lime. — To be shaken before using. 

3. Dilute Solution of Calcium Chloride, i 

(b) Test. 

Two hundred c. c. are rendered alkaline with the milk of 
lime and the calcium solution added as long as a precipitate 



ESTIMATION OF TOTAL NITROGEN. 151 

is formed. After two hours, filter, wash and concentrate 
everything having come through the paper, in the water-bath, 
to the consistency of a thick syrup. Add, while warm, 50 c. c. 
of alcohol (95)%, pour into a beaker and allow to stand for 
eight hours. Again filter and wash, and evaporate to 60 c. c. 
After cooling, add J c. c. of the zinc chloride solution, stir 
with a glass rod and allow to stand forty-eight hours. A 
compound with zinc chloride is formed, which is treated like 
the crystals of uric acid. In 100 parts of this compound are 
found 62.44 parts of creatinin. 

VI. Estimation of Total Nitrogen. 

The principal amount of nitrogen in urine is contained in 
urea, and as Liebig's method includes other nitrogenous, sub- 
stances, this usually suffices. 

The direct method is usually performed by burning with 
soda-lime. 

(a) Reagents. 

1. Fresh Soda by Lime. 

2. Normal Sulphuric Acid, containing 40 grammes of sul- 
phuric acid anhydride in 1 litre of water, every c. c. corre- 
sponding to 0.014 grammes of nitrogen. (See Neubauer and 
Yogel.) 

3. Solution of Caustic Soda, equivalent to the sulphuric 
acid, i. e., 10 c. c. of the one must neutralize 10 c. c. of the 
other. 

4. Litmus Tincture. 

(b) Test. 

Pour 20 c. c. of sulphuric acid into a beaker and then suck 
the greater part into the nitrogen apparatus of Will-Varren- 
trapp. Into a flask holding 100 c. c, soda lime to the depth 
of 2 c. c, and 5 c. c. of urine are put, the flask closed with a 
cork having two openings, and the whole placed into a sand- 



152 EXAMINATION OF THE URINE. 

bath. Through the one opening of the cork the connecting 
tube with the nitrogen apparatus passes, through the other 
passes a fine tube, drawn out at one end and closed. Heat 
the sand-bath as long as bubbles of gas pass through the 
apparatus. When this has ceased, break off the end of the 
fine tube and draw out all the ammonia from the flask. Now 
the contents of the apparatus are poured into the beaker be- 
fore mentioned ; put a few drops of the litmus tincture into 
the fluid, and add the caustic sodium solution until the red 
color is changed to blue. 

If, by decomposition, no ammonia had been formed, we 
would have to have added 20 c. c. of soda to neutralize the 20 
c. c. of normal sulphuric acid. If 14 c. c. only are necessary, 
in proves that 6 c. c. of sulphuric acid have been satisfied by 
the ammonia formed, 1 c. c. corresponding exactly to 0.014 
grammes of nitrogen, the quantity of N. present will equal 
6 X 0.014 = 0.084 grammes N. in 5. c. c. of urine. From w T hich 
the quantity passed in twenty-four hours can easily be found, 

VII. Estimation of Albumin. 

Filter the urine and take 100 c. c. (where little albu- 
min is present), 50 c. c. (where more is present, dilute 
with 50 c. c. of water), or 20 c. c. (where great quanti- 
ties are present dilute with 80 c. c. of water), which is 
to be heated for half an hour in the water-bath. If 
the albumin does not come down in coarse flakes, add 
1-2 drops of acetic acid, and continue to heat. Allow 
the fluid to pass through a weighed filter, and wash 
with distilled water until the wash-water ceases to 
show the NaCl reaction with AgNo 3 . The filter is 
then dried between watch-glasses at 100° C, and 
weighed. 



ESTIMATION OF SUGAR. 153 

VIII. Estimation of Sugar. 

fehlixg's method. 

(a) Solution. 

FeMing's Solution.— In 1,000 c. c. are contained 30,639 
grammes cupric sulphate, 173 grammes pure, crystallized 
tartrate of sodium and potassium, and 500 grammes of solu- 
tion of caustic soda (sp. gr. 1.12). Ten c. c. of this solution 
are reduced by 0.05 gr. of sugar. 

(6) Test, 

The estimation of sugar depends upon the property 
of grape sugar of reducing cupric sulphate in the 
presence of an alkali. For this purpose urine is 
filtered, and, if the quantity of sugar present is not 
too small, it is diluted with water. Usually 10 c. c. of 
urine are diluted with 190 c. c. of water. A burette is 
filled with this mixture. A flask, or porcelain dish, 
is placed upon a wire net, and into it is put 10 c. c. of 
Fehling's solution, diluted with 40 c. c. of water. Now 
heat, and as soon as it boils, add the urine, drop by 
drop. Gradually the fluid becomes ^yellow, then red ; 
finally, all the blue disappears, and the red cuprous 
oxide precipitates very quickly. If allowed to stand 
a little while the solution will be found entirely color- 
less, unless too much urine has been added, in which 
case it will be slightly yellow. The entire discolora- 
tion, then, is the terminal reaction. 

As this can not always be readily determined with 
the naked eye, it is advisable to filter a few drops into 



154 EXAMINATION OF THE URINE. 

a test-tube, testing one part of the fluid, after acidu- 
lating it with acetic acid, with potassium ferro-cyanide 
for copper, and the other with Fehling's solution for 
sugar. If neither are present, then the reaction has 
been completed. 

In the estimation for sugar it is essential to compute the 
amount of urine employed. 

Supposing that we have used 25 c. c. of the urine mixture 
to reduce 10 c. c. of Fehling's solution. The mixture was so 
prepared that 200 c. c. contained only 10 c. c. of urine. In 
order 'to ascertain how much urine there is in 25 c. c. of the 
mixture, we institute the following proportions : 

200: 10:: 25 : x. x = 1.25 c. c. 

Therefore, 1.25 c. c. of urine was able to reduce 10 c. c. of 
Fehling's solution, completely. But the solution is so ar- 
ranged that 10 c. c- will reduce 0.05 gr. of sugar; 10 c. c. of the 
solution being reduced by 1.25 c. c. of urine, the* latter must 
contain 0.05 gr. of sugar. From these data we can easily com- 
pute how much sugar is passed in twenty-four hours. 

If albumin is present it must be removed by the method 
. already described. 

Note. — When Fehling's solution has been kept for some 
time, it becomes self-reducing. It is therefore necessary to 
boil the solution in a test-tube before using, and if reduction 
does not take place, it may be used for the test. The solution 
will retain its delicate properties for years, if it is placed in 
hermetically sealed glass bottles (containing about 15 c. c.) 
and kept in a cool place. 

There are various methods of preparing this solution ex- 
temporaneously. While they may be very serviceable to the 
chemist, who always has his chemicals ready for use, to the 
physician the above mentioned method of preservation will, 
I think, recommend itself. The tablets, consisting of the 



ESTIMATION OF CHLORINE. 155 

compressed salts which go to make up Fehling's solution, and 
held together by some inert substance, I have never used, 
always finding my small bottle in good condition. (Tr.) 

2. — KNAPP's METHOD. 

(a) Solution. 

Ten grammes of pure mercuric cyanide are dissolved in a 
little water. To this is added 100 c. c. of a solution of sodium 
hydrate (sp. gr. 1.145), and the whole diluted to 1,000 c. c; 40 
c. c. of this solution reduce 100 milligrammes of sugar. 

(6) Test 

Heat 40 c. c. of the solution in a beaker, and add diluted 
urine,- as in Fehling's test, until the originally clouded mix- 
ture becomes clear and yellowish. From time to time, a drop 
should be taken out and tested with ammonium sulphide. As 
soon as the spot no longer shows a brown circumference, the 
test is complete. Fehling's method and this one give results 
which do not exactly correspond. 

The fermentation method is much more laborious, and not 
as exact, as Fehling's. Very accurate results are obtained 
with the saccharimeter of Soleil-Ventzke, or the polaris 
trobometer of AVild. (See Xeubauer and Yogel.) 

IX. Estimation of Chlorine. 

1 — after mohr. 

(a) Reagents. 

1. Saturated solution of potassium chromate. 

2. Titrated solution of silver nitrate, containing 29,075 gr. 
of AgN0 3 (18,469 gr. Ag) in a litre, so that 1 c. c. represents 10 
mgr. of NaCl (=6,065 mgr. CI i. 

3. Calcium carbonate. 



156 EXAMINATION OF THE URINE. 



(6) Test. 

Ten c. c. of urine are measured into a platinum 
crucible; add 2 grammes of pure nitre, evaporate to 
dryness over a water-bath, heat over a Bunsen's 
burner until the melted mass no longer contains any 
carbon. Dissolve in a little water and carefully rinse 
the crucible. Solution and rinsings are carefully col- 
lected in a beaker, nitric acid, free from chlorine, is 
then added until a weak acid solution is produced, 
which is then neutralized, carefully, with freshly pre- 
cipitated calcium carbonate. Without regard to the 
precipitate, three drops of chromate. solution are 
added, and then the silver solution is allowed to flow 
into the mixture. As soon as the yellowish fluid 
becomes reddish, it is a sign that all the common salt 
has been converted into chloride, and that the forma- 
tion of silver chromate has begun. At this moment 
the work is completed. 

If for 10 c. c. of urine we had used 9.6 c. c. of the titrated 
fluid, we would have 96 mgr. of NaCI present, as 1 c. c. of the 
fluid indicates 10 mgr. NaCl. 

From this we can readily determine how much NaCl 
present in twenty-four hours. 

If the patient has been receiving iodine or bromine prepara- 
tions, it becomes necessary to remove these from the urine. 
In order to carry this out, add to the solution, as it comes 
from the crucible, sulphuric acid, then a few drops of potas- 
sium nitrite, then shake with bi-sulphide of carbon as long as 
this takes up I. or Br., then neutralize with natrium carbon- 
ate, and proceed as above. 



ESTIMATION OF PHOSPHORIC ACID. 157 

X. Estimation of Phosphoric Acid. 

(«) Reagents. 

1. Solution of Sodium Acetate. — One hundred grammes of 
the salt dissolved in 900 c. c. distilled water and 100 c. c. of 
concentrated acetic acid added. 

2. Solution of Uranium Nitrate, 1,000 c. c. containing 20.3 
gr. pure uranic oxide; 1 c. c. represents 5 mgr. of phosphoric 
acid. 

3. A Solution of Potassium Ferro- Cyanide. 

(6) Test. 
Fifty c. c. of urine are measured into a beaker, 
mixed with 5 c. c. of the solution of sodium acetate, 
and heated in a water-bath. Then add the uranium 
solution as long as a precipitate continues to form. If 
this point can not be determined accurately, place a 
few drops upon a porcelain dish, and, if upon addi- 
tion of the potassium ferro-cyanide, a brownish-red 
boundary line is produced, cease adding the uranism 
solution and again heat in a water-bath. See if a pre- 
cipitate will now form. Usually this is not the case ; 
then a few drops of the uranium solution are added 
so that the ferro-cyanide test succeeds with the boiling 
mixture. The border reaction then sets in, when all 
the phosphoric acid has been precipitated by the 
uranium, in that the next drop, finding no acid, is 
precipitated brown by the ferro-cyanide of potassium. 

If we have used 13 c. c. of the solution, for instance, we 
could establish the following proportion (1 c. c. = 5 mgr. of 
phosphoric acid): 

1 : 5 : : 13 : x ; x — 65 mgr. 



158 EXAMINATION OF THE URINE. 

From which, the quantity of urine in twenty-four hours 
being known, the amount in twenty-four hours can be easily 
computed. 

If we wish to determine the phosphoric acid that is bound 
to the earths, 200 c. c. of urine are precipitated with ammonia. 
The precipitate is collected ; after twelve hours, upon a filter, 
washed with aqua ammonias (1 part in 3 of water), the filter 
perforated, and the precipitate washed into a beaker. The 
precipitate is then dissolved with a small quantity of acetic 
acid, 5 c. c. of the solution of sodium acetate added, diluted to 
50 c. c. and examined as above. 

The difference between the total phosphoric acid and the 
phosphoric acid in combination with the earths, will give the 
phosphoric acid united with the alkalies. 

XI. Estimation of Sulphuric Acid. 

One hundred c. c. of urine, heated and precipitated with 
barium chloride, and the barium sulphate which is formed, 
collected on a filter of known weight, washed, burnt in a 
crucible whose weight is also known, moistened with a few 
drops of sulphuric acid, and again heated. Then the whole is 
weighed, the difference between total weight and the weight 
of crucible + filter, representing the weight of barium sul- 
phate. As 34.33 parts, by weight, in 100 parts of barium 
sulphate, represent sulphuric acid, the latter can be easily 
determined. 

For exact quantitative tests, see Neubauer and Vogel, 
Hoppe-Seyler, etc. 



APPROXIMATE ANALYSIS. 159 

CHAPTER VI. 

Key to the Approximate Analysis of Urine. 

After having allowed the urine to stand for several 
hours, we first determine its physical properties : 

1. The quantity in twenty-four hours. 

2. Color and transparency. 

3. Odor. 

4. Reaction to litmus. 

5. Specific gravity. 

6. Quantity of sediment. 

If a sediment has been formed, it is examined after 
the urine is poured off. If very cloudy, the urine 
must be filtered, and if the filtrate is still cloudy, 
heating slightly will clear it. The sediment is kept 
for further examination. 

Chemical Examination. 

About 15 c. c. of clear urine are taken, and 5 c. c. of 
pure nitric acid are allowed to flow under it. We 
find, by this test : 

1. Albumin. 

2. The urates. 

3. Biliary coloring matters. 

4. Indican. 

When much iodine is present, the ring of coloring 
matter between the nitric acid and the urine is colored 



160 EXAMINATION OF THE URINE. 

yellowish-brown, and the odor of iodine is distinctly 
present. 

Very minute quantities of these substances are only 
separated after some time ; it is, therefore, of import- 
ance to put the vessel aside, and examine the result 
-after a little time has elapsed. The next is the 

(b) Test by Boiling. 

Fill a test-tube one-third full with clear urine, and 
boil over a lamp. If turbidity is produced, there is 
present either albumin or the earthy phosphates. Add 
1-2 drops of acetic acid ; the phosphates are dissolved 
— not so the albumin. Now add liquor potasste, one- 
half the quantity that we added of urine; albumin 
dissolves, but, at the same time, the earthy phosphates 
are brought down in the form of fine flakes. Now 
boil again. If the mixture becomes brown, sugar is 
present; if this does not occur, put the test-tube on a 
stand, and, after having allowed the precipitate to 
settle, determine its quantity and color. 

In normal urine this always is white; if colored, 
then there may be present various coloring matters. 
If it appears blood-red or dichroic, then blood-coloring 
matter is present. In confirmation, albumin must be 
present, and hsemin crystals must be detected by the 
proper methods. Nearly always, blood corpuscles 
will be detected. 

If the precipitate is pink, and the urine does not 
contain albumin, then vegetable coloring matter is 
present (especially after taking senna or rhubarb). In 



APPROXIMATE ANALYSIS. 161 

order to verify this, the urine must, upon addition of 
ammonia, become reddish, which will again disappear 
when acids are added. 

If the precipitate is grayish, then uroerythrin. the 
coloring matter of fever urine, is present. This is 
verified by the presence of a brick-dust sediment, or 
the production of a reddish or flesh-colored precipitate 
upon the addition of a solution of lead acetate. 

A brown color of the precipitate indicates biliary 
coloring matter. If the same is not decomposed, 
Heller's test will give a beautiful play of colors. If 
this fails, it is decomposed: the sulphuric acid test 
must then be increased in proportion as the specific 
gravity is low. and a mixture of urine with potassium 
hydrate will appear darker. 

(c) Test for Normal Coloring Matter of Urine. 

1. Test with concentrated sulphuric acid (Heller's 
Uropaein). 

2. Test for indican with concentrated hydrochloric 
acid and calcium chloride solution. 

(c/) Test for the Xormal Inorganic Salts. 

1. For the chlorides. The vessel in which the test 
(a) has been performed can be used : the two layers 
are stirred with a glass rod. and then one or two drops 
of the silver nitrate solution are added. 

2. For the alkali phosphates with the magnesia 
fluid, and 

3. For the sulphates, with barium chloride. 

e. u.— 12 



162 EXAMINATION OF THE URINE. 



(e) Test for Abnormal Substances. 

If necessary, test for ammonium carbonate, sodium car- 
bonate, hydrogen di-sulphide, leucin and tyrosin. These 
can be determined by the preceding tests. 

(/) Examination of the Sediment. 

First determine color and consistency of sediment, 
(whether crystalline, a powder, flaky, etc.) ; then its 
composition. This can either be done chemically, or 
better, microchemically and microscopically. Finally, 
we determine the organized admixtures (epithelium, 
casts, spermatozoa, etc.). 

Having examined an urine according to this 
method, it is of importance, especially for the begin- 
ner, that all the results are noted in a brief and 
schematic way, so that an oversight can be had, and 
the result easily deduced. 



APPROXIMATE ANALYSIS. 



163 



The following method can be used to great .advan- 
tage: 





Phi 


sical Properties. 




Normal Substances. 


H 2 S0 4 


Test. 


CI 


Ind. 


a 


Eph. 


+ 






U. 




Aph. 


r. 




Sph. 


Abnormal 


Substances in Solution. 






Sediment. 


Result 







164 EXAMINATION OF THE URINE. 

Divide a sheet of paper into four parts; the upper 
for the examination of the physical properties, the 
second for the quantity of normal constituents present. 
The abbreviations employed are as follows : 

H 2 S0 4 test = Sulphuric acid test for coloring matter. 
Ind. = Indican. 

+ 

U. = Urea. 

U. = Uric acid. 

CI. = Chlorides. 

Eph. = Earthy phosphates. 

Aph. = Alkaline phosphates. 

Sph. = Sulphates. 

-To express whether a substance is present in nor- 
mal, greater or smaller quantity, the following signs 
are employed : For an increase, + ? f° r diminution, 
the sign — ; for normal, the letter "n". Great increase 
or diminution are represented by "gr.+" and u gr. — ;" 
also, a moderate increase or diminution by "m + " 
and "m — ." 

The third division is for the normal substances 
found in solution. 

The last for the description of the sediment and the 
result, the diagnosis. A sheet of paper, filled out, 
looks like the following : 



APPROXIMATE ANALYSIS. 



165 



Physical Properties. 

Quantity = 4,000 c. c. 

Pale yellow, somewhat cloudy, acid. 

Sp. gr. = 1,040 ; slight sediment. 



H 2 S0 4 test 


- gr.— 


CI. - - 


- m. — 


Ind. - - - 


- m.+ 


Eph. - - 


gr.— 


+ 1 

u. 




Aph. | 




r - ■ " 


m. — 


- m. — 


u.J 




Sph. J 





Abnormal Substances in Solution. 



Sugar in large quantities. 



Sediment. 

Consists of mucus in normal quantity. 
Microscopically, a few yeast fungi are de- 
tected. 

Result: — Diabetes Mellitus. 



Using a blank like the above will facilitate, not only 
the analysis but also the diagnosis. Coming back to 
the above, we deduce as follows : 

1. From the quantity in twenty-four hours; Poly- 

2. From the specific gravity, and the amount of 
solids found by computation from it : Diabetes. 



166 EXAMINATION OF THE URINE. 

3. From the pale color and absence of the urates; 
the absence of fever. 

4. Finally, from the presence of sugar; Diabetes 
mellitus. 



CHAPTER VII. 
General Diagnosis. 



At the time when the examination of urine con- 
sisted solely in an observation of its physical proper- 
ties, undertaken with preconceived notions of what 
would be found, and when the so-called "urine signs " 
were forced into a ready-made system which had 
naught but chimeras for its foundation, it was no aid 
to the discovery of pathological processes,, and served 
rather, as a cover for ignorance and quackery. 

It is only since organic chemistry and microscopy 
have progressed; since the connection between the 
composition of urine and the changes in the economy, 
on the one hand, and the structure of the urinary 
apparatus, on the other, have been thoroughly recog- 
nized, that the analysis of urine can be termed a 
scientific procedure. Its value in diagnosis is now 
undoubted ; in some cases, it alone gives insight into 
the stage, the nature, and the intensity of the disease. 
It would, indeed, be an error to suppose that all dis- 
eases could be diagnosticated by means of the urine, 
but it would be equally unjust ifiable to neglect its 
examination entirely. 

Before proceeding to the diagnosis of the diseases of 



GENERAL DIAGNOSIS. 167 

the urinary organs, we will first mention those rules 
which are important to urinalysis in general, taking 
them up in the order in which they will be of most 
value to the practicing physician. 

1.' Measure the quantity of urine passed in twenty- 
four hours, and determine whether normal, increased 
or diminished. The normal quantity is about 1,500 c. 
c; if the quantity is very much above this, we have 
polyuria; if very much below, oliguria, and if no urine 
whatsoever is passed, anuria. 

Polyuria may be physiological or pathological. In the 
former instance it is urina potus or urina spastica, and 
in the latter, hydruria or diabetes. In order to make 
this differential diagnosis we compute the amount of 
solids in twenty-four hours, by Trapp's or Haeser's 
coefficient. If this amount is nearly normal (70 gr.) ? 
then we have an urina potus, i. e., an urine with nor- 
mal solids that has been diluted. If the solids are 
diminished, then it is hydruria, as observed in many 
cachexias. If the solids are very much increased, then 
we have diabetes; sugar being detected, in appreciable 
quantity, in the latter instance, it is diabetes mellitus y 
no sugar being present, diabetes insipidus (when the 
nitrogenous substances are increased, azoturia). 

Oliguria can be readily diagnosticated, and occurs 
principally in febrile diseases. The urine usually is 
dark and very much concentrated. In the last stages 
of disease of the kidney, when uraemia sets in, the 
quantity of urine is always diminished. A mild form 
of oliguria may also be congenital; temporarily it is 



168 EXAMINATION OF THE UEINE. 

produced by the abstraction of water, after profuse 
sweats, or after diarrhoea. 

Anuria, the uretha being pervious, can only occur 
in grave disorders of the kidney with uraemia; at 
other times it is found in strictures, calculi and 
neoplasms, as so-called retention of urine. 

Having satisfied ourselves as to quantity, we seek 
to determine whether 

2. The urine is indicative of a febrile state or not. 
From this we can frequently see whether the process 
is acute or chronic, the former being usually accom- 
panied by higher degrees of fever. 

The urine of fever is usually dark, reddish-yellow, 
concentrated, and diminished in volume. If the 
volume is increased rather than diminished, which 
rarely occurs, the coloring matter will, nevertheless, be 
found increased. With the nitric acid test, a distinct 
layer of the urates can always be detected. 

In the presence of an acute exudative process, the 
urine, in the stage of exudation, is concentrated, acid, 
and contains many urates that come down, when 
cold, in the form of brick-dust sediment. Urea, the 
sulphates and the alkaline phosphates are increased? 
while the chlorides are diminished. The chlorides 
diminish with the increase of disease, and may be en- 
tirely absent. 

In the stage of absorption, the concentration of the 
urine gradually diminishes, the reaction becomes 
neutral or alkaline (ammonium carbonate); the 
chlorides are again present in normal quantity, and 
urates (in the form of ammonium urate) and the 



GENERAL DIAGNOSIS. 169 

earthy phosphates are found in the sediment. At the 
same time the quantity of urine may be normal, or 
even diminished. 

We can readily diagnosticate the febrile state, but 
can not diagnosticate the form of fever (except febrile 
diseases of the urinary apparatus). Even in diseases 
of the kidneys, we may err in that we may take an 
accompanying disease to be the principal affection. 
We examine, for instance, the urine of scarlatina. We 
find a febrile state, in addition, however, a desquama- 
tive or parenchymatous nephritis. As a result of the 
uroscopic developments we can only diagnosticate an 
acute nephritis, which evidently only accompanies 
the scarlatina, the latter not being detected by the 
analysis. 

Differential diagnosis between different forms of 
fever, then, is impossible; but, nevertheless, we ought 
to examine the urine, as from it we can discover in- 
crease or diminution in the process, or other compli- 
cations. The reappearance of the chlorides, for ex- 
ample, is considered a favorable sign, their disappear- 
ance, or the appearance of albumin, an unfavorable 
one. 

Among the febrile processes there are some that 
require mention on account of their giving to the 
urine certain characteristic properties. 

We find : 

In jaundice, constituents of bile always present in 
the urine. 

In mild jaundice {icterus levis) produced by absorp- 
tion of bile, we find only a febrile state, and a goodly 



170 EXAMINATION OF THE URINE. 

quantity of biliary coloring matter; the chlorides are 
sometimes diminished. 

In severer forms of jaundice produced by diseases- 
of the liver (icterus gravitis), we find, besides great 
quantities of urates and biliary coloring matter, albumin 
and, sometimes, small quantities of biliary acid. The 
chlorides are usually absent. 

In acute yellow atrophy of the liver we usually find 
an urine rich in biliary coloring matter, having a low 
sp. gr. and acid reaction. Urea is much diminished, 
and we find in its stead leucin and tyrosin. The 
chlorides disappear, and the urates and albumin are 
present, the latter in abundance. Even biliary acids 
may be detected in this urine. Great numbers of 
epithelial tubes and fibrin casts are found in this 
sediment, as well as epithelium from the kidney and 
blood corpuscles. 

. In acute pulmonary affections we find great quantities* 
of urates. In diseases of the heart, or irregularities in 
circulation, we find stasis in the venous system, and, 
as a result, albuminuria (hypersemic kidney). 

In peritonitis we usually find large quantities of 
indican (Senator). 

The urine of meningitis is usually very much con- 
centrated, in proportion to the slowness of the pulse. 
As the differential diagnosis between typhus and 
meningitis is very difficult, frequently clinically im- 
possible, the urine has been looked to for assistance. 
Unfortunately, this can not be relied upon. It is said 
that the urine of meningitis has a high specific 
gravity, a faintly acid reaction, and contains an in- 



GENERAL DIAGNOSIS. 171. 

creased quantity of urates, besides a small amount of 
albumin. It is claimed, in addition, that when the 
urine of this disease is boiled, the earthy phosphates 
are precipitated without the addition of an alkali ; the 
chlorides are always diminished. The urates are 
present; albumin may also be found in considerable 
quantity. At the same time the urine of typhus is 
said to have large quantities of ammonium in solu- 
tion, although the reaction is acid. Much indican has 
been found in meningitis spinalis. In contradistinc- 
tion to meningitis cerebralis, the sp. gr. is said to be 
diminished (Heller). 

In acute articular rheumatism, in addition to high 
specific gravity, acid reaction, increase in urea and iiL 
urates, a great increase in the earthy phosphates is 
claimed as characteristic. The sediment contains- 
pink urates and calcium oxalate colored by uro- 
erythrin. If pericarditis sets in, the chlorides and 
earthy phosphates are rapidly diminished, but the 
uroerythrin becomes even better marked than before. 

If the urine is not colored dark yellowish-red, and 
does not contain urates in large quantity, then we can 
assume that the disease is not accompanied with fever.. 
For a few of those diseases that are without fever, 
therefore, principally chronic, characteristic properties 
of the urine have been described which are enumer- 
ated on account of completeness. 

Chlorosis furnishes a very pale urine, of low sp. gr. 
corresponding with the diminished waste of tissue in 
the body. In hysteria the urine is similar, but the 
quantity is sometimes, and indican is always, increased 



172 EXAMINATION OF THE URINE. 

(urina spastica). Very pale urine is found, also, in 
hydruria and diabetes. In diabetes mellitus the sp. 
gr. is increased ; usually there is found an increase in 
indican, and in the late stages of the disease, albumin 
is present. The other normal constituents are dimin- 
ished in percentage, but increased absolutely (with 
the exception of uric acid). In diabetic urine, hand- 
some yeast fungi, as well as networks of penicillium, 
are frequently found. 

In chronic diseases of the spinal cord there occurs fre- 
quently a pale and light urine, which, in addition to 
much indican, and sometimes albumin, is said to con- 
tain sugar (?). Heller states that in the sediment he 
has frequently observed sarcina. 

In rickets and malacosteon the earthy phosphates are 
very much increased, so that they form a heavy 
deposit. 

In diseases of the bones, when they affect any great 
amount of osseous substance, the calcium salts are 
frequently found increased in the urine, in the form 
of the oxalate as w T ell as the earthy phosphates, both 
in solution and in the sediment. 

A very acid and concentrated urine is found in 
chronic rheumatic arthritis, depositing a copious sedi- 
ment of urates and oxalate of lime. A decided 
increase in earthy phosphates is claimed as character- 
istic. 

In gout the urine is similar to that of the above, 
only that uric acid is diminished in the urine and 
deposited in internal organs. Occasionally, however, 
a, beautiful deposit of free uric acid is found. 



GENERAL DIAGNOSIS. 173 

In intermittens, during the chill, the urine is in- 
creased, pale and transparent: whilst it is dark during 
the period of fever. 

In chronic diseases of the liver, notwithstanding the 
absence of fever, we find a dark, acid and concentrated 
urine. Biliary coloring matter that is not decomposed 
is rarely present. But we find the tests for normal 
coloring matter much increased — usually uroerythrin 
is present. The increase in these coloring matters is 
said to depend upon the presence of decomposed 
biliary coloring matter and increase in its excretion. 
The earthy phosphates are commonly diminished. 
In the sediment are found urates, and sometimes 
oxalate of calcium, both colored by uroerythrin. In 
skin diseases of a chronic nature, and especially in 
those in which a great area of skin becomes disabled 
for perspiration, we frequently find kidney disease as 
a complication, for instance, pemphigus, etc. 

In scorbutus and purpura hemorrhagica, hemorrhages 
from the kidney are not uncommon, as is also the 
case in melanaemia, where, in addition, parenchyma- 
tous disease of the kidney are found. 

In leucaemia the urine is loaded with uric acid, 
lactic and hippuric acids also occurring. 



174 EXAMINATION OF THE URINE. 

CHAPTER VIII. 

Diagnosis of Diseases of the Urinary Apparatus. 

If we can prove the presence of albumin in urine 
which does not contain pus, blood, or any other 
albuminous fluid, then we have before us a case of 
true albuminuria. We are then dealing with a disease 
of the kidney. If blood and pus are present, and 
great quantities of albumin are detected, we are deal- 
ing with mixed albuminuria (Vogel). Great practice 
^lone capacitates one for determining whether albu- 
min is present in sufficiently large quantity to consti- 
tute mixed albuminuria. This can be acquired by 
mixing pus from wounds with normal urine, and 
then testing for albumin. 

Microscopic and Chemical Aids to the Diagnosis 
of Various Forms of Albuminuria. 

(a) TRUE ALBUMINURIA. 

1. Hyper aemia of the Kidney. 

In active hyperaemia, which occurs after the im- 
bibition of much fluid, no albumin is found. The 
quantity in twenty-four hours is very much increased, 
the color pale yellow, or even watery, the sp. gr. very 
low. Normal constituents are usually increased. 

It is only after the kidneys have been over-exerted 
for some time, as in diabetes, that we find albumin 



DISEASES OF THE URINARY APPARATUS. 175 

present in small quantity. It is also found in small 
•quantities Qr$%, usually less) in hyperaemic condi- 
tions of the kidney, which are caused by irritating 
-substances excreted by the kidneys. For instance, 
after the continued administration of balsam copaibae, 
turpentine, cubebs, corrosive sublimate, and other 
acrid remedies. 

The changed chemical composition of the urine 
must also be considered as a cause for an irritated 
condition: i. e., hyperaemia of the kidneys. It is a 
well-known fact, that highly concentrated, or very 
£,cid urine, can cause the most varied symptoms. 
Albumin is occasionally found in such urine, but it is 
usually transient. 

Albumin can be detected in small quantity in ox- 
aluria, and in* the presence of large quantities of uric 
acid; partly on account of mechanical, and partly 
of chemical irritation, especially when the urine is 
very acid, and the crystals of uric acid are lance- 
shaped. In these cases, the internal administration 
of alkalies — excellent solvents for urates and oxalates 
— usually causes it to disappear. This form is not 
infrequently the first beginning of calculus of the 
kidney. 

A transitory presence of albumin in small quantities 
is detected after convulsions, epileptic attacks,. attacks 
of chills and fever, and in various forms of spasms of 
the blood-vessels. This is also frequently the case in 
acute febrile diseases (febrile albuminuria of Barters), 
more especially so, in acute exanthemata, and not in- 
frequently in other inflammatory affections of the 



176 EXAMINATION OF THE UEINE. 

skin, as anthrax, furunculosis, erysipelas, after burns, 
etc. A parenchymatous affection is not uncommonly 
begun in hyperaemia, when the cause continues to act. 

In passive hyperaemia, occurring as a result of stasis 
in the venous circulation, the albumin increases and 
diminishes with increase or diminution of pressure. 

This form of kidney is most commonly found in 
valvular lesions of the heart that have not been com- 
pensated. Regulating the circulation by proper reme- 
dies, causes the albumin to disappear. The hyperaemic 
kidney is also found in chronic diseases of the lungs, 
notably in emphysema; furthermore, in tumors and 
exudations that prevent the flowing back of the 
venous blood; for example, large pleuritic exudations, 
ascites, ovarian tumors and pregnancy. In puerperal 
convulsions we do not always find the hyperaemic 
kidney (Rosenstein), but very frequently paren- 
chymatous nephritis (Bartels). 

As a result of marasmus and cachxia we also find 
this form of disease. 

The urine, in simple hyperaemia of the kidney, is 
as follows: sp. gr. increased, but not always; the 
quantity either diminished or normal; reaction, acid. 

Albumin present in small quantity (yfr% and be- 
low). 

In the sediment are found either no organized ele- 
ments, or blood corpuscles and epithelia from the 
straight uriniferous tubules. Hyaline casts hardly 
ever occur. 

In febrile albuminuria the quantity of urates is 
increased, and that of the chlorides very much dimin- 
ished. 






DISEASES OF THE URINARY APPARATUS. 177 

In the hyperaemic kidney proper (stasis) the quan- 
tity is always diminished, sp. gr. high, color dark, and 
the reaction acid. The urine contains a large quantity 
of urates which frequently form large deposits, and 
make the urine very cloudy. 

Albumin is present \% and above. 

Hyaline casts and kidney epithelium are found in 
the sediment. 

This form can be differentiated from parenchyma- 
tous nephritis by the absence of cellular elements 
(blood, lymph corpuscles and granular epithelium of 
the kidney) and granular casts in the sediment; from 
chronic interstitial nephritis and the amyloid kidney, 
by the dark color of the urine, its high sp. gr., its 
diminished quantity, and its richness in urates. 

Parenchymatous Nephritis. 

There are two forms of this disease : the acute and 
the chronic. The acute form is rarely primary, but 
developed from some other disease ; the chronic is 
usually primary, and forms the second stage of what 
authors call Bright's disease. 

(a) ACUTE PARENCHIMATOUS NEPHRITIS. 

This, again, can be subdivided into its mild form, a 
so-called catarrh of the uriniferous tubules, or des- 
quamative nephritis, and the real acute parenchyma- 
tous (diffuse or croupous) nephritis, the so-called 
Bright's disease. 

E. U— 13 



178 EXAMINATION OF THE URINE. 

(ft) CATARRH OF THE URINIFEROUS TUBULES, OR DES- 
QUAMATIVE NEPHRITIS, 

Attacks, principally, the straight uriniferous tubules. 
The disease lasts from eight to fourteen days, or even 
less. The patients have little fever ; they complain of 
pain in the limbs; weakness and pains in the back. 
Frequently the disease runs its course without com- 
pelling the patient to seek his bed. We rarely find 
oedema. 

The urine presents the following changes : 

The quantity is either normal or slightly dimin- 
ished, the same is true of the sp. gr. The color of the 
urine is wine-yellow, rarely yellow ; the reaction acid. 
It is always cloudy from admixture of cellular ele- 
ments, and frequently deposits a dense sediment. 

The normal constituents are unaltered. Of abnor- 
mal substances albumin is found in T V~i %, and 
traces of blood-coloring matter. 

The sediment is principally made up of an in- 
creased mucous secretion. With the microscope we 
find numerous epithelial cells from the straight 
tubules, usually little altered, but sometimes colored 
brownish by the blood-coloring matter. They fre- 
quently adhere to each other, forming epithelial tubes, 
or they stick to hyaline casts, forming epithelial casts. 
Single hyaline casts are also found, as well as red 
blood corpuscles and lymph corpuscles in great num- 
bers. 

Catarrh of the uriniferous tubules develops as a 
morbid reaction, after the introduction of instruments 






DISEASES OF THE URINARY APPARATUS. 179 

. into the bladder, after catheterization of a sensitive 
bladder, the dilation of strictures, lithotripsy, etc.; in 
addition to this, after acute inflammatory processes, 
especially upon the skin, exanthemata. It may also 
develop ex-contiguo from acute cystitis after gonor- 
rhoea. 

(fi) ACUTE PARENCHYMATOUS NEPHRITIS PROPER. 

This process may be ushered in by very turbulent 
symptoms, or may occur without marked subjective 
symptoms, the latter occurring in cachectic, reduced 
individuals. 

Dropsy is the first symptom that causes uneasiness 
to patient and physician. It appears as the charac- 
teristic oedema of the eyelids and face. Severe cases 
are accompanied by anuria and convulsions. The 
smaller the quantity of urine in twenty-four hours, 
the more intense is the attack, so that anuria lasting 
for some time nearly always results fatally. 

We find the urine as follows : 

The quantity is very much diminished, sometimes 
250 c. c. Sp. gr. is usually increased, the reaction 
acid, the color brownish-yellow and very turbid, fre- 
quently having a large deposit of cellular elements. 

The normal constituents are diminished. 

Of abnormal substances we find large quantities of 
serum-albumin and blood-coloring matter; the quan- 
tity of the former varying from 1, 5 to 6 per cent., so 
that the urine solidifies upon boiling. 

The sediment is usually of a brownish color, and 
consists, principally, of coarse, sometimes long or 



180 EXAMINATION OF THE URINE. 

spiral, casts of fibrin, colored by the blood-coloring 
matter. These sometimes contain a great number of 
white or red blood corpuscles (blood casts), or brown 
epithelial cells of the uriniferous tubules (hemor- 
rhagic). In other cases only debris of cells is found, 
surrounding the nuclei and adhering to or imbedded 
in the substance of the casts. In addition to this, we 
iind cells from the tubules, many blood and lymph 
corpuscles and much detritus, colored brown by the 
blood-coloring matter. 

This form is either a primary disease or a sequela to 
another acute disease, It is very frequent after the 
acute exanthemata, especially after scarlatina; also 
after diphtheria, relapsing fever, phlegmonous inflam- 
mations, erysipelas and carbuncles; after the adminis- 
tration of preparations made from cantharides (can- 
tharidin), as well as after the internal use of caustic 
remedies (corrosive sublimate). It is frequently ob- 
served after catching cold) after burns, inflammatory 
rheumatism, and cholera, and it is not uncommon 
during pregnancy. It also develops during the course 
of chronic parenchymatous nephritis. 

The prognosis is usually favorable, but death may 
ensue from acute ursema, or the form may be changed 
to a chronic inflammation. 

(>') CHRONIC PARENCHYMATOUS NEPHRITIS. 

Dropsy is the first symptom in this form also. 
Fever is absent. , - 

The urine shows the following changes : 

As long as the disease continues to progress, and 



DISEASES OF THE URINARY APPARATUS. 181 

during its acme, the quantity is diminished ; as soon 
as the inflammation recedes, the quantity increases, 
and in the stage of atrophy may be very much in- 
creased. Its color is yellowish, often brownish-yellow ; 
it is turbid from cellular elements, which form an 
appreciable sediment. The reaction is acid, and the 
sp. gr. usually diminished. Normal constituents, 
especially urea, are frequently diminished. 

Albumin is found in considerable quantity (-| to 1 
to 2%), and blood-coloring matter can usually be 
detected. 

In the sediment are found dark, granular casts, also 
half granular casts, i. e., those that are granular in 
spots, the rest of the cast being made up of hyaline 
substance; granular epithelium of the kidney, red and 
white blood corpuscles and molecular detritus. 

In the stage of secondary atrophy, the quantity is 
very much increased, the sp. gr. very much dimin- 
ished, the color pale yellow, the urine turbid and 
having an appreciable sediment. When atrophy 
affects both kidneys, the excretion of normal con- 
stituents, especially of urea, is very much diminished. 
Albumin is present in small quantity, -^ to ^ %. In 
the sediment, granular masses of detritus, granular 
epithelium of the kidney and fragments of granular 
casts are found. - - 

Only in the minority of cases does this form arise 
from the acute form; it generally runs its course in- 
sidiously. It most frequently arises from the acute 
form, after scarlatina and rheumatic processes, after 



182 EXAMINATION OF THE URINE. 

profuse suppuration in the bones, and also from 
nephritis of pregnancy. 

The form that is chronic from the beginning, fre- 
quently develops from purulent processes in bone and 
joints, as a result of syphilis, phthisis, malaria, scrofu- 
losis and cachexia. Intemperance is also considered 
as cause. 

The prognosis is not very favorable. Cases occur in 
which, after dropsy and albuminuria has lasted for 
years, health is regained; but these are exceptions. 
After syphilis and malaria, as well as after osseous 
suppuration, a cure can sometimes be affected by the 
proper remedies. 

5. — Interstitial Nephritis. 

The small amount of interstitial connective tissue 
present in the kidney may be subjected to hyper- 
plastic proliferation or to destruction by suppuration. 
As a result we have two forms of interstitial nephritis: 
the hyperplastic and the purulent. 

(a) HYPERPLASTIC INTERSTITIAL NEPHRITIS — CIRRHOSIS 
OF THE KIDNEY — CONTRACTED KIDNEY PROPER. 

This disease rarely occurs in the young, most com- 
monly in the old. 

It may exist for a long time, and have reached full 
development, without calling attention to its existence 
by symptoms of any kind. Dropsy rarely sets in, and 
when it does, only in the last stage. 

A bounding pulse of high tension, and an enlarge- 



DISEASES OF THE URINARY APPARATUS. 183 

ment of the left ventricle of the heart, are its usual 
symptoms. 

Disturbance of sight is the most common complica- 
tion of this disease, and is frequently the first symp- 
tom which forces a patient to seek help. 

We find the urine as follows : 

Its external appearance is that of normal urine ; 
clear, transparent, of a wine-yellow color. In quantity 
it is usually increased, but polyuria is not always the 
rule. The sp. gr. is either normal, or, more commonly, 
reduced; the reaction is acid. 

The normal constituents are, as a rule, unaltered. 

Albumin is found in moderate quantity (-^ to \ %). 
It may disappear entirely, especially when the patient 
is confined to bed, for which reason we find much less 
albumin in the morning urine than in that which is 
passed during the day. 

Macroscopically, no sediment can be observed. Even 
with the microscope; we frequently fail to find any- 
thing abnormal. Only after careful and repeated ex- 
aminations do we find a single hyaline cast, a blood 
corpuscle, or epithelium from the kidney. 

The prognosis, when diagnosis has been established, 
is usually unfavorable, but the course may be very 
long. 

The etiology is, as yet, dark. 

(6) SUPPURATIVE INTERSTITIAL NEPHRITIS. 

This form may be of traumatic, idiopathic, pyaemic 
or metastatic origin. It frequently originates in chronic 
pyelitis, as the disease of the pelvis spreads to the con- 



184 EXAMINATION OF THE URINE. 

nective tissue of the kidney and causes suppuration. 
This form is the usual termination of cases in which 
there has been surgical interference with the urinary 
organs. For instance., after catheterization of a 
paralytic bladder, after forcible dilatation of strictures, 
after lithotripsy, suppurative nephritis sets in. 

To this form, therefore, the name of "the surgical 
kidney" was formerly given. 

Calculus of the kidney predisposes to this form, 
complicated by large abcesses of the kidney and 
pyonephrosis. 

We find the urine of the following description : 

Its color is yellow ; it is turbid and scanty ; its smell 
is frequently fecal; sp. gr. diminished, and reaction 
either neutral or alkaline. 

The normal constituents, especially urea, are dimin- 
ished; 

Albumin is present in considerable quantity (^ to 
1 %). Blood-coloring matter is also present; we not 
infrequently find large -quantities of ammonium car- 
bonate and sulphide. 

The sediment is copious, and consists principally 
of pus, mixed with blood in greater or less quantity. 
Microscopically, numerous bacteria, molecular detritus 
and epithelia from the kidney, and thick, dentritic 
casts made up of bacteria, are found (Pyelo-nephritis 
parasitica — Klebs) . 

If complicated by parenchymatous nephritis we 
also find dark, granular, thick casts, coming from the 
straight uriniferous tubules. 

The course of the disease is usually acute, and the 



DISEASES OF THE URINARY APPARATUS. 185 

termination, death. In chronic cases the larger ab- 
cesses break into the pelvis. 

Kidney abcesses can only be diagnosticated by 
means of determining the quantity of pus discharged 
— easily accomplished by collecting the urine in ap- 
propriate vessels. Pus which appears and disappears 
suddenly, with the microscopic signs of necrotic 
kidney-tissue (glomeruli and uriniferous tubules), are 
the best indications of the existence of an abcess. 

4. — The Amyloid Kidney. 

Amyloid degeneration of the kidney is usually the 
symptom of a constitutional disorder. It occurs in 
profuse suppuration of bone, as well as in other sup- 
purative processes which last for a considerable length 
of time. In pyonephrosis of one side, the other kid- 
ney frequently becomes amyloid. Scrofulosis, chronic 
tuberculosis, syphilis and malaria, favor the develop- 
ment of this form of disease. It is occasionally found 
idiopathically. 

Amyloid kidney, complicated by parenchymatous 
nephritis, is of frequent occurrence. 

This degeneration develops without producing any 
important symptoms, but it may be laid down as a 
rule, that an amyloid kidney always secretes more 
urine in twenty-four hours than a normal one. The 
quantity never becomes so great, however, as in 
atrophy of the kidney. 

The urine is pale yellow, clear, has a low sp. gr., an 
acid reaction, and is without microscopic sediment. 

The normal constituents are usually diminished. 



186 EXAMINATION OF THE URINE. 

Serum-albumin is constantly found in moderate 
quantity (from -^ to 1 or 2 %). A considerable 
amount of globulin is also found (Senator, Edlefsen), 
which may be looked upon as characteristic of this 
form of disease. 

There are frequently no cellular elements to be 
found in the sediment, but delicate hyaline, or waxy, 
shining, yellowish casts sometimes occur. Amyloid 
epithelium of the kidney is more rarely observed, and, 
in common with the casts, changes to a mahogany 
color upon the addition of an aqueous solution of 
iodine, and upon the further addition of sulphuric 
acid, becomes violet. In the uncomplicated amyloid 
kidney, blood is not found in the sediment. 

The prognosis depends upon the disease at the 
bottom of the kidney disease. In syphilis and malaria 
we will, therefore, have the best results. 

In the differential diagnosis of the various forms of 
true albuminuria, the following additional points 
must be taken into consideration : 

1. If we find a sediment which can be detected 
with the microscope, and is made up of cellular ele- 
ments (blood, pus corpuscle, casts, etc.), we have either 
a parenchymatous nephritis or an interstitial suppura- 
tive nephritis. 

a. In parenchymatous nephritis we find epithelial, 
fibrin and granular casts, kidney epithelium, blood, 
and lymph corpuscles. 

b. In suppurative interstitial nephritis we find pus 
and blood corpuscles, bacteria, sometimes casts of 
bacteria, or short and thick, dark, granular casts. 



DISEASES OF THE URINARY APPARATUS. 187 

2. If the urine is clear, or cloudy with urates, and 
we find no sediment of cellular elements, then we 
either have an hyperaemic kidney, an hyperplastic 
interstitial nephritis, or an amyloid kidney. 

a. The hyperaemic kidney can be differentiated 
from the other two by the diminished quantity of 
urine, by its dark color, its high sp. gr., and frequently 
by the abundance of urates it contains. 

b. The amyloid kidney, by its having globulin and 
waxy casts, and amyloid kidney epithelium. 

Clinically, we find dropsy in amyloid degeneration 
(as well as in parenchymatous nephritis), while in 
true atrophy this is the exception, and only occurs 
late in the disease. 

c. In true atrophy we find hypertrophy of the heart 
and a bounding pulse, neither of which occur in 
parenchymatous nephritis and amyloid kidney. In 
the amyloid kidney we find enlargement of the liver 
and spleen (amyloid degeneration). 

(6) Forms of Mixed Albuminuria. 

It is a characteristic of mixed albuminuria that the 
urine contains more albumin than is called for by the 
pus present in the sediment. It includes those diseases 
of the pelvis of the kidney which, w r hen advanced, 
attack the kidney itself, and complicate pyorrhea with 
true albuminuria. 

As a proof that the papillary portion of the kidney 
is also affected in the pyelitic process, observe the 
occurrence of kidney epithelium in the sediment; 



188 EXAMINATION OF THE URINE. 

also, that after the process has continued for some 
time, the pelvis is dilated at the cost of the papillary 
portion, which has been more or less consumed. 

1. — Pyelitis. 

Pyelitis frequently accompanies acute febrile dis- 
eases, parenchymatous nephritis, and the later stages 
of diabetes mellitus. The use of cubebs, copaiva, etc., 
is sometimes followed by this form of disease. Renal 
calculi, parasites, tumors and tuberculosis in the 
pelvis, are almost always accompanied by it. Ex- 
contiguo, it or pyelo-nephritis develops from stasis of 
urine, as we find in hypertrophy of the prostate, 
paralysis of the bladder, strictures of the urethra etc. 
Pyelitis is produced, also, by compression of the 
ureters by tumors, exudations, and by the retroflexed 
or gravid uterus, and also occurs after gonorrhoea, 
mechanical irritations of the neck of the bladder, and 
of the bladder itself, by surgical instruments, etc. 

Two forms of pyelitis are distinguished, the acute 
and the chronic. We frequently have p Dints offered 
us for the diagnosis of pyelitis calculosa and tuber- 
culosa in the sediment. 

Croupous and diptheritic pyelitis are usually caused 
by such grave diseases that their own symptoms are 
pushed into the background. 

(a) Acute Pyelitis. 

The best type of this disease is found after surgical 
interference with the urinary organs; in the course of 



DISEASES OF THE DRINARY APPARATUS. 189 

acute inflammatory affections, and after gonorrhoea. 
Its urine is moderately diminished in quantity, it is 
dark, cloudy, has a high sp. gr., and is of acid reaction. 
After standing, an appreciable deposit is found. Nor- 
mal constituents unchanged, except in the presence of 
fever, when an increase of urates and diminution of 
chlorides will be observed. 

Albumin is always present in greater quantity than 
would correspond with the comparatively small sedi- 
ment of pus (xfr-i %)• Blood-coloring matter is not 
constant, and when present, only in small quantity. 

The sediment is chiefly made up of mucus, mixed 
with more or less pus. The pus cells are round, and 
frequently many of them are united to form an oval 
or cylindrical plug. These come from the papillae, 
and frequently contain epithelium. We always find 
blood corpuscles: epithelium from the papillary por- 
tion of the kidney, of an oval or pear-shape form, is 
found in great abundance. Frequently two or three 
epithelial cells still cohere. Sometimes we find the 
epithelial cells tinged by blood-coloring matter. 

Epithelial cells with one or two processes, arranged 
like shingles, usually called epithelium from the 
pelvis, is not at all characteristic for pyelitis. Indeed, 
this epithelium from the pelvis can hardly be distin- 
guished from that of the bladder. Besides, these cells 
are not always found in pyelitis, therefore the epi- 
thelium from the papillary portion of the kidney 
alone is characteristic for this form of inflammation. 

In acute pyelitis, epithelium from the kidney is 
always found in great abundance (ten cells, and over, 



190 EXAMINATION OF THE URINE. 

in one field) ; in chronic pyelitis, on the other hand, 
it is not very abundant. 

Acute pyelitis, when the result of surgical inter- 
ference, of acute inflammatory processes or gonorrhoea, 
usually allows of a favorable prognosis, in that a few 
weeks are sufficient to affect a cure. Sometimes the 
acute form becomes 

(b) Chronic Pyelitis. 

In chronic pyelitis the quantity of urine passed in 
twenty-four hours is always increased, so that poly- 
uria may be put down as a characteristic sign of this 
disease. In severe cases, the quantity averages from 
five to six litres. The color of the turbid urine is pale 
reddish-yellow, sometimes a slight greenish shade. 
The sp. gr. is always diminished, and the reaction 
acid. The deposit corresponds with the amount of 
pus present. 

Albumin is always found in larger quantity than 
could be expected from the amount of pus present 
(xo-i %). Blood-coloring matter is always present. 

The sediment has a greenish-yellow color, is flaky, 
does not adhere to the vessel, and consists chiefly of 
pus. The pus cells are, not infrequently, forked and 
branched, in contradistinction to other purulent 
processes in the urinary organs. They also form 
round, oval, or large plugs (from the ductus papillaris), 
which are characteristic of chronic pyelitis. 

Epithelia are found -in small number, and when 
suppuration is profuse they are entirely absent, prob- 



DISEASES OF THE URINARY APPARATUS. 191 

ably because they become pus cells by endogenous 
growth. 

Blood corpuscles are not found in ordinary chronic 
pyelitis, but when the disease is the result of renal 
calculi, tuberculosis, tumors, or entozoa, they are 
never absent. 

The prognosis is rarely favorable. With us, it is 
usually a complication with the formation of calculi. 
The termination in pyonephrosis, then perinephritis 
and external escape of pus, or occasionally into the 
intestine or bladder, is not uncommon, and usually 
occurs in young and healthy individuals. In weak 
patients the pyelitis becomes interstitial nephritis, 
which finally terminates in chronic uraemia. 

(c) Pyelitis Calculosa. 

Real calculi are principally formed by the deposit 
of uric acid in the kidney or pelvis, and the stones 
which pass spontaneously are consequently of a 
yellowish-brown color, and made up of uric acid or 
urates. After hemorrhage or long-continued suppura- 
tion, by the deposit of the earthy phosphates, we also 
have cystin (very rare) and the so-called secondary 
formation, as the origin of renal calculi. Calcium 
oxalate is rarely the primary deposit, but frequently 
forms layers. 

The most common cause for the formation of renal 
calculi is the deposit of uric acid, on account of its 
absolute or comparative excess. This deposit is 
favored by the acidity of the urine, which increases 



192 EXAMINATION OF THE URINE. 

with its concentration, producing those rough crystals 
of uric acid which nearly always form the nucleus of 
these calculi. The predisposition to calculi is to be 
sought for in concentrated, highly acid urine, rich in 
uric acid, especially when it crystallizes in the rough 
or lance-shaped crystals. 

The beginning of this disease can be diagnosticated 
when we find, besides the properties of the urine 
already enumerated, mild albuminuria (hyperaemia 
of the kidney) and single blood corpuscles in the sedi- 
ment. The albuminuria is only temporary, and 
appears when the urine is either very much concen- 
trated or contains a great excess of uric acid. 

The presence of large concretions can be diagnosti- 
cated by the occurrence of parenchymatous hemor- 
rhages. The urine is reddish-brown, or coffee-colored, 
especially after bodily exercise. 

If the calculi are not passed, then there arises 
pyelitis — pyelitis calculosa L 

This may be found either in a mild or severe form. 

The mild form occurs with calculi of small 
diameters, and frequently has characteristic elements 
in the sediment, whilst the severe form can only be 
differentiated from chronic pyelitis by the presence of 
blood corpuscles in the sediment. The latter form is 
usually observed with large calculi, forming a focus 
for pyonephrosis, paranephritis, and emptying of the 
pus. 

The milder form shows the following changes in the 
urine: The quantity is usually normal, sometimes 
diminished, never increased; the color dark, the sp. 



PYELITIS TUBERCULOSA. 193 

gr. normal or increased ; the reaction is very acid, and 
there is frequently a considerable sediment. 

Uric acid is present in excess in the sediment, and 
a layer of urates is to be detected by the nitric acid 
test. 

Albumin is found from -^ to -i- % , always in greater 
quantity than would correspond to the amount of 
pus. Blood-coloring matter is always present, even 
though sometimes in small quantities. 

The sediment consists, chiefly, of lance-shaped uric 
acid crystals (cystin and calcium oxalate), mixed with 
curdled pus. We also find numerous red blood cor- 
puscles (especially microcytes) and epithelia from the 
kidney. 

Diagnosis is made positive by the clinical signs, and 
by the absence of calculi upon sounding the bladder. 

Renal calculi only offer a favorable prognosis when 
small. When they are large, or branched, the prog- 
nosis must be unfavorable, gr, at least, doubtful. The 
greater the suppuration, and the longer its duration, 
the less favorable does the prognosis become. 

The disease is usually unilateral. 

(d) Pyelitis Tuberculosa, 

Pyelitis tuberculosa is, as a rule, a symptom of 
general tuberculosis, or tuberculosis of the urogenital 
apparatus. For this reason, we frequently find it 
complicated by chronic parenchymatous affections of 
the kidney (nephrophthisis — nephritis ulcerosa). In 
cases in which tuberculosis of the pelvis and kidney 

E. U.-14 



194 EXAMINATION OF THE URINE. 

both, exist, we find large, waxy casts, much molecular 
detritus, pus and blood corpuscles, and kidney epi- 
thelium, in the sediment. A great quantity of albu- 
min is found in the urine. 

Simple pyelitis tuberculosa, on the other hand, pro- 
duces the following changes : 

The quantity of urine is not increased very much; 
its color is yellow, frequently brownish-red (on account 
of the admixture of blood). It is always cloudy, has 
a normal or diminished sp.gr., and an acid reaction. 
The sediment is grayish or brownish, and flocculent. 

The excretion of the normal constituents is not 
very much changed. 

Albumin is found in from -^ to \ % . Blood-color- 
ing matter can always be detected. 

The sediment consists of pus, principally, and a 
small quantity of blood; in addition, we find kidney 
epithelia and molecular detritus, mixed with bacteria, 
the latter united so as to form spherical or cylindrical 
bodies. 

The presence of blood corpuscles usually denotes 
an ulcerative process in the pelvis, and will, therefore, 
be observed both in the urine passed during the day 
and during the night; in pyelitis calculosa, on the 
other hand, the urine passed in the morning, or whilst 
the patient is at rest, contains much less blood than 
that passed during the day, or after exercise. In 
tubercular pyelitis the desire to pass water is not 
accompanied with as much pain, and is not so fre- 
quent, as in calculus-pyelitis. In addition, the usual 
symptoms of lithiasis are absent. 



PYELITIS TUBERCULOSA. 195 

The diagnosis is much easier if we find hard, plastic 
exudations in the testicles, scrofulous cicatrices, en- 
largement of glands, other diseased processes in bone, 
deep fistulae in ano. etc. 

When general tuberculosis is present, the prognosis 
must be unfavorable. In tuberculosis of the genital 
organs, when it affects young and healthy individuals, 
improvement or comparative health may be secured; 
for example, after the removal of a tubercular testicle. 

Note. — The brilliant discovery of Koch makes the diagnosis 
of all tubercular processes a comparatively easy one. In 
pyelitis the sediment is examined for the presence of the 
bacillus of tuberculosis ; it is carefully collected by decanting 
the urine, and then a small quantity taken, spread out 
upon a slide, or rubbed between two thin covers. The thin 
layers are then carefully dried, and the* coloring matter 
applied to them. For the purpose of staining the bacilli, 
there are several that may be used ; the original method of 
Koch, slow but sure, or one of the modifications to insure 
rapidity. The method most convenient to the clinician and 
practicing physician is carried out by taking aniline oil, heat- 
ing this in a test-tube until it has cleared up, and then adding 
an alcoholic solution of fuchsin until a rich red color is pro- 
duced. This fluid is then poured upon the thin layer of 
sediment and allowed to stand for from fifteen to forty-five 
minutes — or the thin cover may be floated upon a watch-glass 
containing the aliline oil and fuchsin. The longer the ex- 
posure to the action of the fluid, the more positive are we 
concerning the result. After the staining has been effected, 
the slide or thin cover is washed with distilled water, put into 
a 33^ aqueous dilution of HN0 3 , and decolorization of the 
stained spot then proceeded with. This completed, we again 
wash with distilled water, and then mount in glycerine and 



196 EXAMINATION OF THE URINE. 

examine, if possible, with a homogeneous lense and a con- 
denser. The ordinary high powers, however, are sufficient 
for the detection of the bacillus, especially to one experienced, 
yet it is always safer to examine with the combinations 
recommended by Koch. 

In echinococci we sometimes find pyelitis, which, 
however, is not to be distinguished from any ordinary 
pyelitis. It is only when the tumor has emptied into 
the pelvis that we find the characteristic cysts in the 
sediment, as well as single scolices with a double row 
of hooklets, or remnants of them, and single hooklets. 

In bilharzia haematobia, pyelitis accompanies cystitis, 
and is always complicated by copious parenchymatous 
hemorrhages. Numerous blood and pus corpuscles, 
kidney and bladder epithelia, and fibrin coagula, en- 
closing the characteristic ova of the bilharzia, are 
found in the sediment. Large quantities of albumin 
and blood-coloring matter are present in solution. 

Para- or perinephritis can not be diagnosticated from 
their urine, as the latter, even in a severe attack, fre- 
quently produces a normal urine. 

2. — HEMATURIA. 

Strictly speaking, this is a symptom, not a disease, 
but as it accompanies so many diseases, and as these 
diseases can not always be determined, we have to be 
satisfied with the diagnosis, "hsematuria from un- 
known causes." For this reason we have thought best 
to treat of it here. 



HEMATURIA. 197 

Hemorrhages from the urinary apparatus may be 
divided into three classes : 

a. Hemoglobinuria (hematinuria of Vogel); 

b. Parenchymatous hemorrhage, and 

c. Copious hemorrhage, produced by the rupture of 
large blood-vessels. 

1. Hemoglobinuria is characterized by a reddish- 
brown, brownish-black urine, from which, even after 
it has stood for hours, no red deposit forms. It retains 
its uniformly reddish-brown color, because the blood- 
coloring matter is dissolved. The reaction is usually 
acid, and sp. gr. diminished. It contains much 
haemoglobin and methemoglobin. In the sediment, 
hemorrhagic epithelia and brown molecular detritus 
are sometimes found. Blood corpuscles are not 
present. 

2. In parenchymatous hemorrhage we also observe a 
reddish-brown, frequently coffee-colored urine, which 
will retain its color for a long time, but deposits a 
reddish-brown sediment, consisting of red blood cor- 
puscles. Its reaction is acid, its sp. gr. varies, and it 
holds hemoglobin (more or less altered) in solution. 

For the parenchymatous hemorrhage, the sediment 
is characteristic. Blood corpuscles of various sizes are 
found in it. The round, normal corpuscles, with 
depressions, are frequently not to be found in it at all, 
but they appear, instead, globular, spherical, and 
colored brown. They are often entirely colorless, and 
of a ring-like appearance. Very large corpuscles, cor- 
puscles of one-fourth the normal size, and some as 
small as specks of dust, are seen in one and the same 
field. 



198 EXAMINATION OF THE URINE. 

These microcytes, which have so frequently, in 
modern times, been observed in the blood of patients^ 
were long since known to exist in urine from paren- 
chymatous hemorrhage, and were considered charac- 
teristic of it. 

3. In the hemorrhage coming from the rupture of 
large vessels, the urine is either dark reddish-yellow or 
red, similar to venous blood. The reaction is, com- 
monly, neutral or alkaline. The sp. gr. varies. The 
urine usually contains traces of coloring matter in 
solution ; it is only when much ammonium carbonate 
is present, a rare occurrence, that considerable quan- 
tities are dissolved. 

Usually, the urine from rupture of large vessels 
deposits all its blood, after standing for several hours, 
in the form of a copious red sediment, in which the 
blood corpuscles appear of their normal color, size and 
shape. 

Albumin can always be found in this kind of urine. 

These three forms of hemorrhage may originate in 
the bladder, the pelvis, or the kidney, and we are not 
always so fortunate as to be able to state where the 
blood comes from. 

1. We seek to utilize the reaction for differential 
diagnosis. It is generally accepted that in hemorrhage 
from the kidney it is acid ; from the bladder, alkaline. 
But this is not always the case; indeed, the one can 
only occur when hemorrhage is complicated by puru- 
lent catarrh of the pelvis or bladder. Here the 
reaction on litmus is not decisive, for, in large hemor- 
rhages, we find the alkalinity of the blood neutralizing 



HEMATURIA. 199 

the acidity of the urine, and we may have an alkaline 
reaction even if the blood comes from the kidney. 
The internal administration of alkalies might be 
sufficient to make the urine alkaline, or the amount 
of pus formed in the pelvis of the kidney, with its 
alkaline reaction, might be sufficient to neutralize the 
urine — in these cases we would have an alkaline 
reaction, and yet the hemorrhage not from the 
bladder. 

On the other hand, it can not be denied that hemor- 
rhages occur from the bladder in which the reaction of 
the urine is acid. This is always the case, when there 
is no purulent catarrh of the bladder, and when the 
hemorrhage is not very great. 

Of greater importance than the reaction, is the 
detection of ammonium carbonate. When this is 
present in large quantity, the likelihood of hemor- 
rhage from the bladder is greater, more especially if 
we rind crystals of the triple phosphate in the sedi- 
ment at the same time. 

2. The color of the urine is of very great importance 
in this respect. The older practitioners have always 
associated its reddish-brown or brownish-black color 
with hemorrhage from the kidney, and the light red 
with hemorrhage from the bladder. This is not 
altogether correct. The dark colors are produced by 
decomposed haemoglobin (methsemoglobin), and can 
only occur when blood has been intimately mixed 
with urine and retained within the body for some 
time. This is the case in parenchymatous hemor- 
hages, where the blood is gradually mixed with the 



200 EXAMINATION OF THE URINE. 

urine, and the blood corpuscles remain a long time in 
a comparatively large quantity of fluid containing 
substances which are undergoing a retrograde meta- 
morphosis ; the constituents of the urine have time to 
exert their destructive influence upon the red cor- 
puscles, converting the haemoglobin into brown met- 
haemoglobin. 

For this reason the urine in parenchymatous hemor- 
rhages, even in such as come from the bladder (cancer), 
takes brown tints upon itself. 

It is an entirely different matter when hemorrhage 
is produced, by the rupture of larger vessels (haemor- 
rhoids of the bladder). Here a large quantity of 
blood is suddenly introduced into the bladder, and as 
suddenly dilates it. This is followed by tenesmus, and 
the blood is passed before the urine has had time to 
act upon the haemoglobin. 

As hemorrhages from the bladder are produced, as a 
rule, by rupture of large vessels, and those from the 
kidney are parenchymatous, we can readily under- 
stand how the different color of urine becomes a very 
valuable diagnostic point. 

3. The specific gravity is of importance in that in 
hemorrhage from the kidney or pelvis, some disease is 
usually present which produces polyuria, therefore 
low sp. gr.; while in hemorrhages from the bladder 
there is, as a rule, no change in this respect. 

4. If coagula are present they sometimes point posi- 
tively to the seat of the lesion. 

If the coagula are soft and have the color and con- 
sistency of fresh, coagulated blood, they have not 



HEMATURIA. 201 

existed for a long time; but if they are discolored, 
they are old, and have been retained for some time. 
Short, rod-like coagula sometimes come from the 
dilated pelvis (Simon), and are found after hemor- 
rhages from the kidney ; they were formerly considered 
as concrements made up of pure fibrin (Heller). 

Large, irregular, shred-like coagula are said to come 
from the bladder. We must call especial attention to 
the fact that the rod-like coagula alone can be con- 
sidered of diagnostic value. If they are present we 
can state positively that the seat of hemorrhage is 
above the ureters, for the long coagula are molds of 
the ureters. The irregular coagula, on the other 
hand, are not all characteristic. They may be pro- 
duced in the pelvis as well as in the bladder. 

It may even happen that fluid blood, poured out in 
the kidney, passes into the bladder and coagulates 
there. 

Moreover, coagula are not constant in hemorrhages. 
Parenchymatous and copious hemorrhage will rarely 
produce them. They occur when the blood comes 
from vessels of smaller calibre. 

5. The most important of all the aids to diagnosis 
is microscopic examination of the sediment. 

The so-called blood casts and hemorrhagic epithe- 
lium of the kidney are characteristic of parenchyma- 
tous hemorrhages from the kidney. They are not 
found, however, after copious hemorrhages from larger 
vessels. It is highly probable that kidney epithelia 
are present, but they are covered over by the great 
numbers of blood corpuscles, and can not be detected. 



202 EXAMINATION OF THE URINE. 

Hemorrhages from the bladder are frequently not at 
all characterized by the sediment. We sometimes 
find an increase of epithelia from the bladder, and 
crystals of triple phosphate. 

After this description of the micro-chemical charac- 
teristics of hemorrhages from the urinary apparatus, 
we will proceed to discuss the diseases in which they 
occur, and, at the same time, seek new diagnostic 
points. 

I. Hemoglobinuria (with or without methsemoglo- 
binuria) occurs in hemorrhagic diathesis, scorbutus, 
congestive chills, in putrid typhus fevers, and, in fact, 
in all diseases which are accompanied by blood disso- 
lution; after the inhalation of arseniuretted hydrogen, 
carbonic acid gas, and other similar substances. We 
also find hemoglobinuria after transfusion with ani- 
mal blood, especially in cases where much blood has 
been used. 

II. Parenchymatous Hemorrhages may come from 
any part of the urinary apparatus. 

a. In addition to the diseases already enumerated, 
hemorrhages are found from the kidney, usually 
associated with hsempglobinuria; also: 

1. Occasionally, in acute febrile diseases, especially 
in the exanthemata, where the hemorrhage represents 
a higher degree of hyperaemia. 

2. In the majority of cases of chronic parenchyma- 
tous nephritis. 

3. As a rule, in atheromatous degeneration of the 
vessels of the kidney. 

4. In thrombosis of the renal vein, occurring in 



HEMATURIA. 203 

general cachectic conditions ; in puerperal fever, with 
phlebitis of the femoral and uterine veins; further- 
more, accompanying serious injuries of the kidney, 
sometimes with traumatic nephritis; finally, as a 
result of compression by tumors in the neighborhood 
of the hilus. 

Thrombosis of the renal veins sometimes occurs in 
infants suffering with intestinal catarrh. According 
to 0. Pollak this may be recognized as follows : The 
child becomes jaundiced, a great diminution of urine 
follows, and the sediment contains blood casts, blood 
corpuscles, and hemorrhagic kidney epithelium. 

Hemorrhages from the kidney are furthermore ob- 
served : 

5. Constantly in renal calculi, when severe pyelitis 
has not developed. Besides the elements which are 
characteristic of calculi, the sediment contains blood 
corpuscles and kidney epithelia. 

6. In cancer of the kidney, where nothing suspicious 
is found but the hemorrhage. We have never found 
cancer cells or tissue in the sediment, but it may occur 
when the cancer grows into the pelvis of the kidney. 

In small children, large tumors, the size of a fist, 
are found in the kidney, without one being able to 
detect a sign of albuminuria. Hematuria, therefore, 
is not always present in tumors of the kidney, but is 
a very common symptom. 

7. In nephrophthisis or in caseous inflammation of 
the kidney, of the pelvis, and the ureters. In addition 
to the microcytes, we find in the sediment, kidney 
epithelium, pus cells, much molecular detritus, 



204 EXAMINATION OF THE URINE. 

numerous vibriones and cocci; sometimes, waxy casts, 
mixed with casts made up of bacteria. 

b. Hemorrhages from the bladder are observed : 

1. In stone in the bladder and in catarrhal ulcers 
at the neck of the bladder. Hematuria is of a mild 
nature. 

But in both cases microcytes can not be detected in 
the sediment. All the red corpuscles are of normal 
size. If catarrh of the bladder is also present we find 
its characteristic urine. 

Hematuria in vesical calculus becomes more in- 
tense after exercise, and ceases when the patient is in 
bed. Hematuria in catarrhal ulcers, situated at the 
neck of the bladder, usually originating in gonor- 
rhoea, takes place at the end of micturition, when the 
sphincter of the bladder begins to contract. 

2. In papilloma and villous carcinoma of the blad- 
der, parenchymatous hemorrhages also arise from the 
papillomatous proliferations of its mucous membrane. 
Not infrequently, we find in the sediment necrotic 
papilla tissue, which facilitates diagnosis. (See chapter 
on cancer.) 

c. Parenchymatous hemorrhages throughout the 
entire apparatus occur. 

1. Sometimes, after the emptying of a paretic or 
paralyzed bladder with the catheter. If the entire 
urine is drawn off, a quantity of which probably has 
remained for years in the bladder, because the paretic 
bladder was unable to pass it, an hyperaemia ex- vacuo 
must occur, which becomes the more intense the 
thicker the muscular coat of the bladder, and the 



CYSTO-PYELITIS AND PYELO-CYSTITIS. 205 

greater its inability for contraction. At the same 
time the pressure in the kidney is also changed, pro- 
ducing a parenchymatous hemorrhage. 

2. They are also observed in Egypt, as a result of 
the bilharzia hsematobia. Emboli of the vessels of the 
mucous membrane are produced by the ova of the 
distoma haematobium. The sediment is characteristic 
for this disease. 

III. Large hemorrhages after the rupture of vessels only 
occur in tumors and varicose vessels at the neck of 
the bladder. 

In tumors they only occur when the cancer has 
existed for a long time and begins to ulcerate. In the 
so-called haemorrhoids of the bladder, the bleeding is 
very profuse, coming on very suddenly and, after one 
or two days, rendering the patients very anaemic. It 
usually lasts for several days, then leaves the patient 
perfectly well, returning after months or years. In. 
the sediment we only find blood corpuscles of normal 
size. 

In diphtheritic and croupous processes of the blad- 
der, occurring after dissolution of the blood, Ave also 
find blood in the fetid, ichorous and alkaline urine. 

3. — Cysto-Pyelitis and Pyelo-Cystitis. 

Under this designation, a purulent catarrh, which 
affects pelvis, ureters and bladder, is understood. If 
the pelvis is principally affected it is cysto-pyelitis, 
but if it is the bladder, then we term it pyelo-cystitis. 

We determine by characteristic signs whether the 
bladder or pelvis is most affected. 



206 EXAMINATION OF THE URINE. 

If pyelitis prevails, polyuria will usually be present ; 
the urine will be of neutral or faintly alkaline re- 
action ; sp. gr. low, and the purulent sediment will 
not adhere to the glass. Albumin will be present in 
greater quantity than is proportionate to the pus, and 
in the sediment, pus corpuscles, kidney and bladder 
epithelium, and crystals of the triple phosphate will 
be found. The pus corpuscles are well preserved, and 
occasionally united into plugs. 

If cystitis prevails, polyuria is absent; the urine is 
very alkaline, its sp. gr. normal, or only slightly 
diminished. The sediment is pasty, and adheres to 
the vessel. Albumin is present in quantity corre- 
sponding with mixed albuminuria, and considerable 
quantities of ammonium carbonate can be detected. 

The pus corpuscles in the sediment are very much 
swollen, and lie between great numbers of the triple 
phosphate crystals ; the sediment also contains single 
kidney and bladder epithelia. 

Cysto-pyelitis and pyelo-cystitis frequently occur in 
stricture of the urethra, in hypertrophy of the pros- 
tate, and in paresis or paralysis of the bladder. 

Cysto-pyelitis and pyelo-cystitis may easily originate 
from cystitis or pyelitis, by direct continuity of the 
tissues. It is not rare for cystitis to alternate with 
pyelo-cystitis, and pyelitis with cysto-pyelitis. 

Prognosis depends upon the cause and prevailing 
disease. 

(c) Forms of False Albuminuria. 

False albuminuria is distinguished from the other 
forms by the fact that true albumin is present in 



CYSTITIS. 2(K 

quantities which correspond with the quantity of 
blood or pus present in the urine. The albumin 
which is found is from pus and blood serum, and 
when these disappear suddenly, as after the rupture of 
an abcess or varix into the bladder, the albumin will 
disappear also. 

We have seen the derivation of true and mixed 
albuminuria, and can arrive at the seat of lesion pro- 
ducing false albuminuria by exclusion : the bladder, 
urethra, and their adnexa. 

1. — Cystitis — Catarrh of the Bladdp:r. 

* Cystitis exists in two forms, the acute and the 

chronic, each of which has three degrees. 

In cystitis of the first degree, urine contains neither 
pus nor albumin, but simply an increased amount of 
mucus, and has an acid reaction. In the second 
degree it contains albumin and pus. has an alkaline 
reaction, and a greenish, mucilaginous sediment. The 
third degree is characterized by ichorous, fetid urine, 
much albumin, pus and blood, and a marked alkaline 
reaction : it is the result of ulcerative processes in the 
bladder, and is not infrequently accompanied by sup- 
purative nephritis. 

Urine usually has an alkaline reaction, in catarrh 
of the bladder, and many practitioners, even to-day. 
diagnosticate this form of disease by means of litmus 
paper. This test is usually reliable, but there are 
cases of cystitis in which the urine has an acid re- 
action. This is only the case, however, with urine 



208 EXAMINATION OF THE URINE. 

which has been recently passed, as it becomes alkaline 
after standing a few hours. 

(a) Acute Catarrh of the bladder of the first degree pre- 
sents the following peculiarities : 

The quantity of urine is not diminished. The urine 
has a normal or dark wine-yellow color, and is turbid.. 
The reaction is faintly acid, but changes in a few 
hours to alkaline. There is considerable sediment,, 
very cloudy, and not solid. 
' Excretion of normal constituents is unchanged. 

Carbonate of ammonium is the only abnormal sub- 
stance which can be detected. 

The sediment consists principally of cloudy mucus. 
Microscopically, Ave detect mucus corpuscles (young 
cells) and epithelia from the bladder, in small quan- 
tity. After a few hours, small numbers of the crys- 
tals of the triple phosphate are found. 

This form represents a diseased condition of the 
mucous membrane, as it occurs in prostatitis after 
gonorrhoea, and after the introduction of instruments 
into the bladder and urethra. 

(b) Chronic Catarrh of the first degree is characterized 
by a wine-yellow, exceedingly cloudy urine, whose sp. 
gr. is normal, and whose quantity is not increased. 
The reaction of the fresh urine is acid, but quickly, 
becomes alkaline. The sediment is considerable and 
cloudy. Sometimes the urine has a peculiar pene- 
trating odor, and the cloudiness, consisting principally 
of bacteria, is never completely deposited. 

The only thing abnormal in the solids is the pres- 
ence of carbonate of ammonium in small quantities. 



CYSTITIS. • 209 

The sediment is the same as that of the preceding- 
form, with the addition of bacteria. 
• This form of urine is found in patients who are 
forced to use the catheter in order to empty the 
bladder; in hypertrophy of the prostate gland, paresis 
of the bladder, and similar obstructions to the passage 
of urine. In elderly women, who have given birth to 
many children, or who suffer from any diseased con- 
dition of the uterus, this condition is nearly always 
present. 

c. Acute Catarrh of the second degree is distinguished 
from the preceding forms, chiefly by the amount of 
pus in the urine. 

The urine is of a dark wine-yellow T color, and is 
turbid. The turbidity is produced by mucus and pus. 
while in catarrh of the first degree, the cloudiness is 
produced by mucus alone. The quantity and sp. gr. 
are normal, but the reaction is alkaline. The sedi- 
ment is greenish-yellow, and adheres to the vessel. 
The only change found in normal constituents is, that 
part of the urea is changed to ammonium carbonate. 
Albumin is found in quantities to correspond with 
the amount of pus present, and carbonate of ammo- 
nium is present in great quantity. 

The sediment consists of alkaline pus, mixed with 
crystalline and amorphous earthy phosphates. Blood 
corpuscles, ammonium urate, and gieat quantities of 
epithelium from the bladder are detected with the 
microscope. 

This form of the disease occurs in hypertrophy of 
the prostrate ; after lithotripsy of large and hard 
e. u.— 15 



210 # EXAMINATION OP THE URINE. 

calculi; after the dilatation of strictures; after cathe- 
terization, or the introduction of other instruments. 
Also, after gonorrhoea and acute prostatitis, and, finally > 
after catching cold, especially depending upon the 
action of cold and moisture. It occurs in women 
after operations upon the uterus, or vagina, in perime- 
tritis and pericystitis. It is sometimes observed after 
the administration of cantharides or other medica- 
ments, and it is said that drinking of badly fermented, 
so-called " young " beer will also produce it. 

d. Chronic Catarrh of the bladder of the second degree 
produces urine, which is nearly identical with that 
just described. In addition, as in the chronic catarrh 
of the first degree, we fine bacteria in the urine. 

In the sediment the pus corpuscles are very much 
swollen, their outlines indistinct and the nuclei dis- 
tinctly visible; frequently, the latter alone are observed 
imbedded in an homogeneous, granular mass. 

Sometimes the pus is entirely dissolved in the alka- 
line urine, giving to the latter a syrupy, tenacious 
consistency. 

This form is found in hypertrophy of the prostate 
gland, in paresis of the bladder and in diseases 
causing obstruction to the passage of urine. 

e: Acute Catarrh of the third degree includes those 
processes that have been called cystitis parenchymatosa 
and pericystitis. 

Although we are not always able to diagnosticate 
these diseases from the urine, yet diagnosis is very 
much facilitated by its examination. 

If the quantity of pus is very variable, we can 



CYSTITIS. 211 

sometimes deduce the rupture of an abscess of the 
bladder. 

The urine presents the same changes as that of the 
second degree, with the exception that the purulent 
sediment does not adhere to the vessel, and that it 
contains many blood corpuscles. 

/. Chronic Catarrh of the third degree is a purulent 
catarrh complicated by an ulcerative process in the 
bladder. 

The urine is of a dirty brownish-yellow color, has a 
fecal smell, its reaction is strongly alkaline and the 
turbidity is produced by pus, mucus and bacteria. 
The sp. gr. is diminished; the sediment of the same 
color as the urine, and adheres to the vessel. 

The normal constituents are diminished. 

Of abnormal constituents, we find a great quantity 
of albumin, blood coloring matter, ammonium car- 
bonate, and ammonium sulphide. 

The sediment consists of ammoniacal pus, mixed 
with blood and earthy phosphates. Large quantities 
of bacteria, molecular detritus and single epithelia 
from the bladder are found with the microscope. 

This form of the disease occurs in paralysis of the 
bladder, and in great hypertrophy of the prostate 
gland. It is easily complicated by pyelo-nephritis, 
and symptoms of uraemia or ammonaemia close the 
scene. 

Similar urine occurs in tuberculous ulcers of the 
bladder and in diptheria. 

In croupous affections of the bladder, as they some- 
times occur, especially in women, large reddish-white 



212 EXAMINATION OF THE URINE. 

membranes, which consist of fibrin, are discharged 
with the urine. 

The practicing physician is apt to confound the 
symptoms of spasm of the bladder with those of 
cystitis. Examination of the urine alone will make 
this diagnosis easy. 

In spasm of the bladder the urine is generally clear. 
When it is turbid it is due to the amorphous earthy 
phosphates which are about to be deposited. The 
urine is pale, and has a faintly acid or neutral re- 
action. 

In boiling, the urine grows cloudy, earthy phos- 
phates and carbonates are deposited, which are readily 
dissolved by the addition of a small quantity of acetic 
acid. Sodium carbonate can sometimes be detected. 

Albumin, pus, carbonate of ammonium, etc., are 
absent in spasm of the bladder. 

Calcium carbonate, crystalline calcium phosphate 
and amorphous earthy phosphates are found in the 
sediment. Crystals of the triple phosphate and epithe- 
lial cells from the bladder are absent. 

2. — Neoplasms of the Bladder. 

Having discussed the varieties of hemorrhage from 
the bladder under the head of " Haematuria," it now 
becomes necessary to state, in detail, the uroscopic 
signs found in the various kinds of neoplasms of the 
bladder. 

We find the following: 

a. Simple fibrous polyps, with a pedicle and hang- 
ing intq the bladder ; they are very rare. 



NEOPLASMS OF THE BLADDER. 213 

b. Medullary sarcomata ; also very rare. 

c. Epitheliomata, and 

d. Villous, or vascular tumors. 

1. Fibrous polyps produce symptoms of catarrh of 
the bladder of the second degree, and only when they 
ulcerate do we find blood in the sediment. 

We are not able to diagnosticate this form of 
disease, as it does not cause any characteristic histo- 
logical elements to appear in the sediment. 

2. Medullary sarcomata produce a similar urine, ex- 
cept in the later stages, when they are followed by 
catarrh of the third stage. The urine is sometimes of 
a greenish-brown color and has a very offensive odor. 
In the sediment is found much molecular detritus, 
but nothing characteristic. 

3. Epitheliomata usually develop very slowly, some- 
times producing a catarrh of the second, sometimes 
of the third degree. The sediment always has more 
or less of a bloody tint. 

Upon microscopical examination we sometimes find 
numerous peculiar, small epithelial cells (in addition 
to blood and pus corpuscles), which are occasionally 
as numerous as the pus cells. 

They are small, round or oval, not unlike kidney 
epithelium. They are sometimes caudate, or have 
two or three small processes. The nuclei are occasion- 
ally very large, several being visible in one cell. Ten 
or twelve of these cells adhere and form ragged epith- 
elial structures. 

Although the diagnosis of epithelioma is not justi- 
fied by this appearance, any suspicion which may be 



214 EXAMINATION OF THE URINE. 

held concerning the nature of the disease is very much 
strengthened by this microscopical appearance. 

4. Papillary or vascular tumors can always be diag- 
nosticated from the urine. 

Two kinds of this form of tumor can be recognized ; 
1, papillary proliferations (papilloma) of the mucous 
membrane of bladder, and 2, the true villous cancer. 

Parenchymatous hemorrhages are common to both 
forms; both may be accompanied by catarrh of the 
second degree, sometimes of the third. Only in the 
first form may the papillomatous proliferations necrose 
and fall off, and the patient be restored to health. In 
the second, cachexia is developed, and the patient 
dies. 

The villous cancer is made up of a more or less soft 
mass, similar to medullary sarcoma tissue, which 
grows into the posterior, inferior wall of the bladder, 
so that a thickening or tumor may be felt by intro- 
ducing the finger into the rectum. The surface of this 
tumor is formed by a peculiar villous, proliferating 
tissue, made up of ecstatic capillaries and a covering 
of epithelium. 

Papilloma of the bladder is confined to the mucous 
membrane of the bladder. No tumor or thickening 
of the walls of the bladder can be felt from the rectum. 

We can not differentiate these two forms from each 
other by means of examining the urine — indeed, a 
villous cancer frequently develops from a papilloma. 
There are a few points that may make the differential 
diagnosis possible. 

If we find well-developed villi covered over with a 



NEOPLASMS OF THE BLADDER. 215 

thin layer of epithelium, it is usually considered that a 
papilloma is present; if the layer of epithelium is so 
thick that the vessels within the villus can no longer 
be distinctly seen, we assume that a cancer is present. 

But this is of less importance than the detection of 
intumescence in the walls of the bladder and the pres- 
ence of a cachexia. 

On account of this difficulty of diagnosis it seems 
fit to discuss both forms together. 

In these tumors the urine presents the following 
changes : 

The quantity is not increased, the sp. gr. is normal. 
The color is that of parenchymatous hemorrhages, 
and the turbidity is produced by blood and pus cor- 
puscles. The reaction is, usually, faintly acid; only 
when the tumor becomes larger and the cystitis more 
pronounced, followed by abundant suppuration, does 
the reaction become alkaline. The sediment is flaky, 
brownish or brownish-red, and contains fibers or small 
ragged bodies of the same color. 

The consistency of the urine is that of a thin fluid, 
but temporary fibrinuria is sometimes observed. This 
is the only disease that produces fibrinuria in our zone. 

When passed, the urine, in these cases, is thin, but in a few 
minutes it congeals to a gelatinous mass that can not be 
poured from the vessel. After shaking for some time the 
urine again becomes fluid, and may then be used for exami- 
nation. Its color is not always blood-red, sometimes only pale 
reddish-yellow. 

It is always accompanied by tenesmus. The fibrinuria can 
be explained by assuming that the blood vessels in the mus- 



216 EXAMINATION OF THE URINE. 

cular layer are compressed by the violent cramp-like contrac- 
tion of the muscular substance. The veins are compressed 
more than the arteries, and stasis takes place in the vessels of 
the villi. If the pressure is very great, rupture takes place, 
if not, the plasma of the blood is forced out, which afterward 
coagulates on account of the great amount of fibrin contained 
in it. 

The normal constituents are unchanged : 

Albumin and blood-coloring matter are frequently 
found in great quantity. We must especially notice 
the fact that the quantity of albumin is greater than 
would correspond with the quantity of pus and blood, 
due probably to increased pressure in the vessels. We 
must be careful not to make the diagnosis of disease 
of the kidney, in these cases, unless undoubted casts 
are found in the sediment. Small pieces of villi are 
apt to mislead the inexperienced observer, being looked 
upon as casts. 

Ammonium carbonate can not always be detected. 

When much blood or pus are present it becomes 
very difficult to see the cancer tissue — indeed, it is 
then only by chance that particles are observed. It is 
best, therefore, to select a comparatively clear and 
colorless urine for examination. Let the urine deposit 
its sediment, and from this fis^ out the reddish flakes 
for microscopical examination. 

The sediment consists either of blood only, or of 
blood mixed with pus. The blood is found in a fluid 
condition, but coagula are always found. The latter 
can be distinguished from the villous tissue by their 
dark red color. We not infrequently find villous tis- 



NEOPLASMS OF THE BLADDER. 217 

sue inclosed by these coagula. The blood corpuscles 
are the same as in parenchymatous hemorrhage. 

Villous tissue presents itself in manifold forms, ac- 
cording to the reaction of the urine, but we shall be 
disappointed, if we think to find it as beautiful and 
characteristic as text-books represent. Entire living 
villous tissue does not occur in urine; it is only when 
a catheter is introduced, that we occasionally find it 
adhering to the openings of the instrument. Necrotic 
tissue is usually found in the sediment, which may 
also vary greatly in form. 

In the beginning of the disease we find beautiful 
and characteristic villi (see fig. 14). The villi being 
necrotic, and their blood vessels ruptured, we rarely 
find whole blood corpuscles in their interior. 

Beautiful villous tissue is most apt to be found in 
papilloma of the bladder. We are not always so 
fortunate, however, as to find it. Especially in cancer, 
with thick epithelial covering, is it impossible to dis- 
cover villi; as the epithelial layer is beginning to 
necrose, the individual cells can no longer be discov- 
ered. The epithelial layer is infiltrated by pus and 
blood corpuscles, and is alive with bacteria. Branched 
structures which represent the stroma and blood ves- 
sels are sometimes observed in this detritus. 

These histological points are not sufficient for diag- 
nosis, but we find other bodies, with the microscope, 
which make it positive. 

If we examine the necrotic tissue with high powers, 
we will find parts of the epithelial layer of a brownish 
color. If the urine is of acid reaction, a closer exami- 

E. U.— 16 



218 EXAMINATION OF THE URINE. 

nation will show that these parts or spots are made up 
of crystals of haematoidin. If a drop of fuming nitric 
acid is allowed to flow under the thin slide, a change 
of color from green to blue and violet will take place. 
These crystals are characteristic of hemorrhagic tissue, 
and consequently of importance for our diagnosis. 

We also detect crystals which are only found in 
villous tissue, and therefore pathognomonic. They 
are small, colorless, circular rosettes, which are only 
soluble in concentrated acids and alkalies. They are 
probably calcium oxalate, as they effervesce when 
treated as calcium oxalate in examining calculi. 

When the urine is highly alkaline, the villi are en- 
crusted with ammonium urate and the earthy phos- 
phates. In this case the patient feels as if gravel 
were passing through the urethra, and is apt to 
demand an examination for stone. 

3.— Calculi of the Bladder. 

When stones are present in the bladder, we usually 
find blood in the urine after exercise, which disappears 
again when the patient is at rest. Urine passed during 
the day is more bloody than that passed at night, in 
contradistinction to other forms of hematuria, where 
the blood is unchanged by time. 

Calculi frequently cause cystitis. When small and 
smooth, as uric acid, they cause catarrh of the first 
degree; when larger, or of a roughened surface (phos- 
phates, oxalate), they are accompanied by catarrh of 
the second degree. Hemorrhage into the bladder also 
depends upon the conformation of the surface. 



DISEASES OF THE URETHRA. 219 

The reaction of the urine depends upon the amount 
of catarrh present. 

It is of importance to determine whether an affection 
of the kidney is also present. (See " mixed albumin- 
uria.") If this is detected it is probable that the same 
process is going on in the kidney as in the bladder. 

Determination of the chemical composition of the 
calculus depends upon the chemical properties of the 
urine. The amorphous and crystallized combinations 
found in the sediment form the outer layers of the 
calculus. The nucleus, in the majority of cases, con- 
sists of uric acid (90%). 

4. — Diseases of Urethra and the Prostate Gland. 

These do not always produce marked changes in the 
urine. Acute and chronic prostatitis, as well as 
hypertrophy of the prostate gland, are usually com- 
plicated by catarrh of the bladder of the first and 
second degree. In prostatitis we usually have cystitis 
of the first degree ; in hypertrophy, either of the first 
or of the second, to correspond with the amount of 
retention of urine. When the prostata is very much 
hypertrophied, we usually find spermatozoa in the 
sediment. It seems that the increase in glandular 
tissue compresses and destroys the muscular tissue of 
the ejaculatory duct, thus preventing its closure. 

In spermatorrhoea the urine is either neutral or alka- 
line. Upon boiling, it becomes cloudy, and earthy 
phosphates are precipitated, which dissolve upon the 
addition of acetic acid (Heller's bone-earth) ; albumin 
is not present. Besides numerous spermatozoa, we 



220 EXAMINATION OF THE URINE. 

find in the sediment, calcium carbonate, crystalline 
calcium phosphate, and sometimes the triple phos- 
phate. Before making the diagnosis it is necessary to 
know whether the urine has been passed immediately 
before an emission or coitus, or not, as we always find 
spermatozoa in the urine after an ejaculation. 

In acute and chronic gonorrhoea we find pus cor- 
puscles and single cylindrical epithelia from the 
urethra. 

If the urine does not permit the diagnosis of the 
origin of the pus, then it will be well to collect the 
urine in two vessels (Thompson). That passed first 
will contain all the pus from the urethra — that 
passed afterward will contain the secretions from the 
bladder or pelvis of the kidney. 

The threads of gonorrhoea, which may be found 
after normal cases of gonorrhoea, are commonly 
formed in the accessory glands of the urethra. It is 
only the very long threads, very rare, that may be 
formed in the urethra. These threads occur in two 
varieties — the one, thick, long, and possessing at one 
end a head-like dilatation ; the other, thin and short, 
and without the dilatation. The former coming from 
the prostatic portion of the urethra, the latter from 
Littres' glands. 

Under the microscope they consist of pus corpuscles, 
mixed with cylindrical epithelia, and imbedded in an 
homogeneous substance. 

In croup of the urethra, small, white, membranous 
or tubular structures are passed with the urine, to- 
gether with pus and blood. 



INDEX. 



PAGE. 

Acidity — Estimation of, . . . • 143 

Albumin — Estimation of, .... 152 

Modifications of, . . . . . 74 

Albumin — In Jaundice, in Acute Yellow Atrophy, in 
Diseases of the Heart, 170; in Meningitis, 171; in 
Diabetic Affections, in Chronic Diseases of the 
Spinal Cord, 172: in Active Hyperemia of the 
Kidney, in Oxaluria, in the Presence of much Uric 
Acid ; after Convulsions, Epileptic Attacks, Chills 
and Fever, and certain Spasms of the Blood Vessels, 
in Acute Exanthemata, 175; in Anthrax, Furuncu- 
losis, Erysipelas, after Burns, and in Passive Hy- 
peremia of the Kidney, 176; in Hyperaemic 
Kidney Proper, 177; in Desquamative Nephritis. 
178; in Acute Parenchymatous Nephritis, 179: in 
Chronic Parenchymatous Nephritis, 181; in Hyper- 
plastic Interstitial Nephritis, 1 83 ; in Suppurative 
Interstitial Nephritis, 184; in Amyloid Kidney, 186; 
in Acute Pyelitis, 189 ; in Chronic Pyelitis, 190 : in 
Pyelitis Calculosa, 193; in Pyelitis Tuberculosa, 
194; in Hemorrhage resulting from the Rupture 
of Large Vessels, 198 ; in Cysto-Pyelitis, in Pyelo- 
Cystitis, 206; in Cystitis, 207; in Acute Catarrh of 
the Bladder (second degree), 209; in Chronic Catarrh 
(third degree), 211 ; in Spasms of the Bladder, 212; in 
Papillary and Vascular Tumors, 216. 

Albumin — Ludwig's Explanation of its Absence from 
Normal Urine, 06; to Compare Quantity from Day 
to Day, 74; Approximate Determination of Quantity 
e. r.-i7 



222 INDEX. 

Albumin — page, 

in Twenty-four Hours, by Nitric Acid Test, by Boil- 
ing Test, 72, 73; Occurrence, 65, 67, 71; Forms in 
which it Occurs in Urine, 67; Explanation of its 
Presence, 71, 72; to Test by Boiling, 69; by Nitric 
Acid, 68; Other Tests for, 71. 

Albumin — Modifications of, Globulin, Myosin, Pep- 
tone, ....... 74 

Albuminuria — False, its Origin, .... 207 
Febrile, of Bartels, ..... 175 

Mild, as an Aid to the Diagnosis of Eenal Calculi, 192 

Albuminuria — Mixed, 174; Forms of, Characteristics, 
Diseases Included in Complications, Parts of the 
Kidney which are Affected, 187; True, 174. 

Alkali Salts — Occurrence of, . . .94 

Alkapton, ...... 76 

Allantoin, . . . . . . .91 

Ammonia — Note on, ..... 65 

Duchek on, . . . . . . 65 

Ammonium — In Typhus, ..... 171 

Ammonium — Carbonate and Sulphate, in Suppurative 
Interstitial Nephritis, 184; Carbonate in Hemor- 
rhage from the Kupture of Large Vessels, 198, 199; 
in Pyelo-Cystitis, 206 ; in Acute Catarrh of the Blad- 
der (first degree), 208; in Chronic Catarrh of first 
degree, 208; in Acute Catarrh (second degree), 209; 
in Chronic Catarrh (third degree), Sulphide in 
Chronic Catarrh (third degree), 211; in Spasm of the 
Bladder, 212 ; in Papillary and Villous Tumors, 216. 

Ammonium Carbonate — Origin of, in Urine, 91, 92; 
Development of, in Urine, 92; Reaction of Urine 
in Diseases of the Bladder, 92; Occurrence of, 92; 
Reaction of Urine Containing, 92; Test for, 92, 93; 
When Found, 93. 

Ammonium Urate— Occurrence of, 101; Appearance of, 
101, 102 ; Tests for, 102. 

Anuria — Occurrence of, . . . . • 168 



INDEX 223 



Arteriol-E Interlobulares, «, ,13 

Arteriole Rect^e, . . . . , .13 

Arthritis — Chronic Rheumatic, Urine of, . . 172 

Atrophy of the Liver — Acute Yellow, Urine of, . 170 

Ascites — its Effects on the Urine, . . . 176 

Bacillus Tuberculosus, ..... 195 
Bacteria — Their Occurrence, .... 129 

Leptothrix, their form, length, and movement; how 

to distinguish them from Yibriones, . . . 129 

Monad, ....... 128 

Rod, 129 

Vibrio, ....... 129 

Zooglea Form, . . . . . .127 

Bacteria and Cocci — Casts made up of, Occurrence, 
Shape and Size, Origin, Structure, 127; Casts of, with 
Pus Cells, 127; Casts having Uric Acid imbedded in 
them, 127 ; Casts to which Calcium Oxalate or Uric 
Acid adhere, 128. 
Bacteria — In Suppurative Interstitial Nephritis, 184 ; in 
Pyelitis Tuberculosa, 194; in Nephrophthisis, 204; 
in Chronic Catarrh of the Bladder (first degree), 208 ; 
in Chronic Catarrh (second degree), 210; in Chronic 
Catarrh (third degree), 211. 
Badecker — Test for Sugar, . 76-77 

Bartels Febrile Albuminuria, . 175 

Effect of Puerperal Convulsions on the Kidneys, 176 

Bence Jones, . . . . . . 79 

Benzoic Acid— Occurrence of, . . . .91 

Bile — Constituents of, in Urine of Jaundice, . . 169 

Biliary Acids — Occurrence of, 89; Strassburger's Test 
for, 90 ; Pettenkofer's Test for, 90 ; Method of Sepa- 
ration from Urine, 90; Neubauer's Modification of 
Pettenkofer's Test, 91; in Jaundice, 170. 
Biliary Coloring Matter— Occurrence of, 86; Occur- 
rence of Biliprasin and Bilirubin, 86, 87; Method of 



224 INDEX. 

Biliary Coloring Matter — page. 

Differentiation between Biliprasin, Bilirubin, and 
Changed Biliary Coloring Matter, 87; Gmelin's, 
Heller's and Ultzman's Tests for Unchanged Color- 
ing Matter, 87, 89; when found in Urine, 89. 

XSILHARZIA HiEMATOBIA, ..... 135 

xiccompanying Diseases, .... 196 

Biliprasin. — See Biliary Coloring Matter. 
Bilirubin. — See Biliary Coloring Matter. 
Bladder— Acute Catarrh of (first degree), Urine, Occur- 
rence, Significance, ...... 208 

Chronic Catarrh of (first degree), Urine, 208; Occur- 
rence, 209. 
Acute Catarrh of (second degree), Urine, Occurrence, 209 
Chronic (second degree), Urine, Occurrence, . . 210 

Acute (third degree), Urine, Nature of Disease, . 210« 

Chronic (third degree), Nature of Disease, Urine, 
Occurrence, Occurrence of Similar Urine, . . 211 

Bladder — Calculi of, Urine of, Diseases Caused by, 218; 
Hemorrhages from Diseases in which they Occur, 
204. 
Membrane, 15; Structure, Trigonum, Epithelium, 
Blood Supply, Course of Blood Vessels, 16; Nerve 
Fibres, 17. 
Neoplasms in, ..... . 212 

Papilloma of, ..... 214 

Spasms of, . . . . . . . ' 212. 

Blood Coloring Matter — Occurrence of, in Urine, 84; 
Color, as Affected by Haemoglobin and Methsemo- 
globin, 84; Occurrence of Haemoglobin and Methae- 
moglobin, 84; Change from Haemoglobin to Methae- 
moglobin, 85 ; Haemin Test for, 85 ; Other Methods 
of Obtaining the Crystals, 86 ; Spectroscopic Exami- 
nation, 86; Occurrence of Haematinuria, 86. 
Blood Corpuscles in Urine — In Acute Yellow Atrophy, 
170; in Desquamative Nephritis, 178; in Axute 
Parenchymatous Nephritis, 179; in Chronic Paren- 



INDEX. 225 

Blood Corpuscles in Urine — page. 

chymatous Nephritis, 181 ; in Hyperplastic Intersti- 
tial Nephritis, 183; in Acute Pyelitis, 189; in Chronic 
Pyelitis, 191 ; Renal Calculi, 192 ; their Presence and 
Significance in Pyelitis Tuberculosa, 194; in Bilharzia 
Hamiatobia, 196 ; in Hemoglobinuria, 197 ; in Pa- 
renchymatous Hemorrhage, their Characteristics, 
197, 201 ; in Hemorrhage from the Rupture of Large 
Vessels, 198; in Stone of the Bladder, in Catarrhal 
Ulcer of the Neck of the Bladder, 20-4 ; in Epithelio- 
mata, 213 ; in Papillary or Vascular Tumors, 215. 
Blood Corpuscles — Method of Detection by the Micro- 
scope, 120; Shape, Appearance, Arrangement, 120; 
Changes Effected in their Appearance by Diluting 
the Urine, by the Action of Salts, in Hsematinuria, 
121; Presence of Albumin in Connection with Pus 
Corpuscles, 121 ; Presence of Blood Coloring Matter. 
121. 
Boettger's Test for Sugar, . . . . .177 

Bone — Diseases of the, Urine of, 172 

Bruecke on Sugar,. . . ■ . . 75, 78 

Bunsen's Method of Estimating Urea, . . . 148 

Cachexia — As a Cause for Hypersemic Kidney, . . 176 

Calcium Carbonate — Occurrence, Appearance. How to 

Recognize, Microscopic Test, .... 113 

Calcium Oxalate, 134; its Source, 104; Occurrence of, 
104 ; Crystalline Form of, 104, 105; to Collect Crystals 
of, 105; Resemblance to the Triple Phosphate Crystal, 
and Differentiation between them, 105. 

Calcium Phosphate, 16; in Spermatorrhoea, 220; Crys- 
tallized, Formula for, 111 ; Occurrence, 111 ; Appear- 
ance Under the Microscope, 111; How to Distin- 
guish, 111. 

Calcium Salts — Oxalate, in acute Articular Rheumatism, 
171; in Diseases of the Bone, 172; in Chronic Rheu- 
matic Arthritis, 172; in Chronic Diseases of the Liver, 



226 INDEX. 

Calcium Salts — page. 

173 ; Oxalate, in Pyelitis Calculosa, 191 ; in Spasm of 
the Bladder, 212. 
Calculi — Analysis of, Method of Procedure, 138; Method 

for Analysis, . . . . . . 139 

Large, Urine of, . . . . .192 

Renal, Formation of, 191 ; Predisposing Causes, 192. 
Calculus — Cystin. . . . . . .135 

Cancer — Histological Elements of, . . 132-134 

Carbonates— Earthy, in Spasm of the Bladder, . . 212 

Calcium, in Spermatorrhoea, . . . 220 

Casts — Their Importance in Diagnosis of Kidney Dis- 
ease, 122 ; Cases in which Albumin is Present with- 
out Casts, 122. 
Blood, in Hsematinuria, ..... 201 

Fibrin, in Acute Yellow Atrophy, 170; in Acute 

Parenchymatous Nephritis, 179. 
Coarse Fibrin, General Appearance, Form, Color, Size, 
Origin, . . . . . .123 

Bloody, their Composition, Origin and Color, . 123 

Epithelial, in Desquamative Nephritis, 178 ; in Chronic 

Pyelitis, 190. 
Granular, in Chronic Parenchymatous Nephritis, 181: 

in Suppurative Interstitial Nephritis, . . . 184 

Finely Granular, ..... 124 

In Papillary or Villous Tumors, .... 215 

Hyaline, Size, Shape, General Appearance, 124; Spiral 
Casts, 124; How to Examine them Under the Micro- 
scope, 125. 
Tape-like, their Shape and Origin, 125; Effect of 

Alkaline Urine on Hyaline Casts, 125. 
In Hyperemia of the Kidney, 176, 177 ; in Desquama- 
tive Nephritis, 178; in Chronic Parenchymatous 
Nephritis, 181; in Hyperplastic Interstitial Nephritis, 
183 ; in Amyloid Kidney, 186. 
Uric Acid, Occurrence, 126; Appearance Under the 
Microscope, 127. 



INDEX. 227 

Casts — page. 

Waxy, 125, 126 

In Amyloid Kidney, 186; in Pyelitis Tuberculosa, 
194; in Nephrophthisis, 204. 
Cells — In Walls of Malphigian Capsule, . . 9 

Epithelial, in Desquamative Nephritis, 178 ; in Acute 
Parenchymatous Nephritis, 179; in Acute Pyelitis, 
189; Spasm of the Bladder, 212; in Epitheliomata, 
213. 
Pus, in Acute Pyelitis, 1S9 ; in Chronic Pyelitis, 190 ; 
in Nephrophthisis, 203 ; in Epitheliomata, 213. 
Chlorestearin — Occurrence of, 109 ; Form, 109. 
Chlorides — Average Quantity. 156; to Determine the 
Quantity, 57 ; Significance of their Absence, 58. 
The Quantity of, as Affected by Diabetes Insipidus, 
59; by Chronic Diseases with Diminished Digestive 
Power, 59 ; by Dropsy, 59 ; by Acute Febrile Diseases, 
58; by Paroxysms of Fever, 59; by Great Mental 
or Physical Labor, 59 ; by Meningitis, 58 ; by Pneu- 
monia, 58 ; by the Introduction of much Salt to the 
System, 59 ; by Typhus, 50 ; in Urine of Mild Jaun- 
dice (icterus levis, 170. 
In the Presence of an Exudative Process, as Influ- 
enced by the Increase of Disease, in the Stage of 
Absorption, 168 ; in Jaundice, 170 ; in Acute Yellow 
Atrophy of the Liver, 170 ; in Meningitis, 171 ; in 
Febrile Albuminuria, 176; in Acute Pyelitis, 189. 
Chloride (Sodium) — Microscopic Appearance, 57 ; Com- 
parative Quantity, 56. 
Chlorine — Estimation of, . . . 155 

Chlorosis — Urine of, .... 171 

Cloudiness — In Normal Urine, Contents of, . . 31 

Coagula — In H&ematinuria, 200 ; in Stone of the Bladder, 
in Catarrhal Ulcers at the Neck of the Bladder, 209. 
Cocci — In Nephrophthisis, ..... 204 
Color — Bluish, 31; Dark Brown to Black, 30; Green 
of a Dirty Shade, 31 ; Cause of High Color, 30 ; 



228 



INDEX. 



Color — page. 

Cause of Light Color, 30 ; Nearly Colorless, 29 ; Blood 
Red to Garnet, 30; Variations of, 29. 
In Fever, 168, in Acute Articular Rheumatism, 171; 
Chlorosis, 171 ; in Hydruria and Diabetes ; in Chronic 
Diseases of the Spinal Cord, 172; in Intermittens, 
173 ; in Hyperemia of the Kidney, 174 ; in Desquam- 
ative Nephritis, 178; in Acute Parenchymatous Ne- 
phritis, 179; in Chronic Parenchymatous Nephritis, 
181; in Hyperplastic Interstitial Nephritis, 183; in 
Suppurative Interstitial Nephritis, 184; in Amyloid 
Kidney, 185 ; in Acute Pyelitis, 189 ; in Chronic 
Pyelitis, 190 ; of Renal Calculi, 191 ; in Large Concre- 
tions, 192; in Pyelitis Calculosa, mild form, 192; in 
Pyelitis Tuberculosa, 194 ; Hemoglobinuria, 197 ; in 
Parenchymatous Hemorrhage, 197 ; in Hemorrhage 
from the Rupture of Large Vessels, 198, 199 ; in Acute 
Catarrh of the Bladder (first degree), 208 ; in Chronic 
Catarrh of first degree, 208; in Acute Catarrh of sec- 
ond degree, 209 ; in Chronic Catarrh of third degree, 
211 ; in Medullary Sarcomata, 213 ; in Epitheliomata, 
213; in Papillary or Vascular Tumors, 215; in Fibri- 
nuria, 215. 

Coloring Matter — Abnormal, 



Biliary Acids, 

Biliary Coloring Matter, 

Blood Coloring Matter, 

Coloring Matter of Plants, 

Uroerythrin, 

Normal, Urine Indican, 

Urochrom, 

Urobilin, 

Uroglaucin, 

Urohaematin, 

Urophaein, 

Uroxanthin, 

Urrhodin, 



9, 82 
89-91 
86-89 
84-86 
83-84 
82-83 
51-55 

50 
49-51 

51 
. 50 

50 
. 51 

51 



INDEX. 229 



■Coloring Mattes of Plants — How to Recognize, 83; 
Methods of Differentiation from Uroerythrin and 
Blood Coloring Matter, 84. 

Coloring Matter — Biliary, in Jaundice; in Acute Yellow 
Atrophy, 170; in Chronic Diseases of the Liver, 173. 
Blood, in Desquamative Nephritis, 178 ; in Parenchym- 
atous Nephritis, 179 ; in Suppurative Interstitial Ne- 
phritis, 184; in Chronic Pyelitis, 190; in Pyelitis 
Calculosa, 193; in Pyelitis Tuberculosa, 194; Bilharzia 
Haematobia, 196; in Hemoglobinuria, 197; in Hemor- 
rhage from the Rupture of Large Vessels, 198; in 
Chronic Catarrh of the Bladder ^ third degree), 211 ; 
in Papillary or Vascular Tumors, 216. 

Concentration of Urine — Of the Urine of Fever ; in 
the Presence of an Exudative Process, in the Stage 
of Absorption, 168, 169 ; in Meningitis, 170 ; in 
Chronic Rheumatic Arthritis, 172; in Chronic Dis- 
eases of the Liver, 173; in Renal Calculi, 192. 

Concretions — Their General Appearance and Structural 
Characteristics, the Cystin Calculus, 135; Micro- 
scopic Examination, 136 ; their Origin, Chemical 
Composition of Calculi, How to Examine their 
Structure, Structure of Calculi, Importance of the 
Nucleus as a Clue to the Origin of Stone, 136 ; Divi- 
sion of Calculi into Groups, Primary and Secondary 
Calculus Formation, Metamorphous Calculi, 137 ; 
Composition of Calculi from the Bladder, 138. 

Consistency — In Papillary or Vascular Tumors in Fibrin- 
aria, ....... 215 

( Abnormal), 28, 29; Effect of Albumin Upon, 29; Effect 
of Bile Upon, 29 ; Effect of Fibrin Upon, 28 ; Effect of 
Pus Upon, 28; Normal, 28; Effectof Sugar Upon, 29. 

Constituents (Accidental) — Heavy Metals which have 
been Found, 94; Alkali Salts, 94; Mineral Acids, 94: 
Metallic Bases, 94; Aromatic Acids, 94; Conditions 
under which Carbonates of the Alkalies are Found, 



230 



INDEX. 



Constituents (Abnormal) — page. 

94, 95 ; Reaction of the Urine in such Cases, 95 ; 

Method for Detection of Iodine, 95 ; Salicilic Acid, 95. 

Constituents (Abnormal) — Albumin, . . . 65, 75 

Ammonium Carbonate, . \ . . 91,93 

Biliary Acids, . . . . . . 89, 91 

Coloring Matter, Abnormal, ... 82, 89 

Hydrogen Bisulphide, .... 93 

Leucin and Lyrosin, . . . . 80, 82 

Sugar, . . . . . . 75, 80, 

Constituents (Normal) — In Diabetic Urine, 172; in Chlo- 
rosis, 172; in Desquamative Nephritis, 178; in Acute 
Parenchymatous Nephritis, 179 ; in Chronic Paren- 
chymatous Nephritis, 181; in Hyperplastic Inter- 
stitial Nephritis, 183; in Suppurative Interstitial 
Nephritis, 184 ; in Amyloid Kidney, 185 ; in Acute 
Pyelitis, 189 ; in Pyelitis Tuberculosa, 194 ; in Acute 
Catarrh of the Bladder, first degree, 208; in Acute 
Catarrh, second degree, 209 ; in Chronic Catarrh, 
third degree, 211 : in Papillary and Vascular Tu- 
mors, 216. 
Constituents (Normal Inorganic) — Ammonia, . . 65< 

Chlorides, . . . . . . 56, 69 

Iron, . . . . . . .65 

Phosphates, . . . . . . 59, 63 

Silicic Acid, . . . . . .65 

Sulphates, . . . . . 63, 65 

Constituents (Normal Organic) — Coloring Matter, 49, 55 

Hippuric Acid, ..... 55 

Kreatinin, . . . . . . .55 

Mesoxalic Acid, ..... 55 

Oxalic Acid, . . . . . .55' 

Urea, 35,42 

Uric Acid, 42, 4^ 

Xanthin and Disulphonic Acid, ... 55* 

Constituents— Quantitative Detection of Urinary, Con- 
ditions Necessary for, 142; Method of Collecting 



INDEX. 231 

Constituents — page. 

Urine, 143; Method of Estimating Acidity, Test 
Solution for the Purpose, and the Test, 143 ; Estima- 
tion of Total Solids, and Method of Procedure, 144; 
Estimation of Urea, Reagents Necessary for Liebig's 
Method, 144 ; Method of Testing, and the Chemical 
Reaction, 145, 148; Bunsen's Method of Estimating 
Urea, 148; Knop-Hiifner's Method, Solutions Needed, 
and Test, 148, 149; Estimation of Uric Acid, Method 
of Procedure, 149, 150; Estimation of Creatinin, 
Necessary Reagent, 150; Test, 157; Estimation of 
Total Nitrogen, the Necessary Reagents, 151 ; Test, 
151, 152; Estimation of Albumin, 152; Estimation of 
Sugar, by Fehling's Method, Solution, Test, 153, 155 ; 
by Knapp's Method, Solution and Test, 155 ; Estima- 
tion of Chlorine, after Mohr; Reagents, 155; Test, 
156 ; Estimation of Phosphoric Acid, Reagents, Test, 
157-158; Estimation of Sulphuric Acid, 158. 

Convulsions — Puerperal, their Effect on the Kidney 

(Rosenstein), . . . . . . 176 

Creatinin — Estimation of, ... 150 

Cystin — In Pyelitis Calculosa, .... 191 

Crystalline Form, 105; General Appearance, 105, 107; 
Tests for, 106 ; Resemblance to Colorless Uric Acid, 
105 ; Occurrence of, 107. 

Cystitis — In Bilharzia Hsematobia, * . . . 196- 

In its Three Degrees, . . . . . 207 

Cysto-Pyelitis — Nature of the Disease, 205 ; Occurrence 
and Origin. 206. 

Diabetes, ....... 167 

Urine of, ...... 172 

Insipidus, ....... 167 

Mellitus, ...... 167 

Diagnosis — General, Method of Procedure, . . 167 
Diagnosis of Kidney Abcesses, 185; of Renal Calculi, 
192; of Large Concretions, 192; in Pyelitis Calculosa, 



232 INDEX. 

Diagnosis — page. 

193 ; of Pyelitis Tuberculosa, 195 ; of Perinephritis, 
196 ; of Hemorrhages from the Urinary Apparatus, 
198, 205 ; of Cystitis, 207 ; of Chronic Catarrh of the 
Bladder (third degree), 212; Fibrous Polyps, 213; of 
Epitheliomata, 213; Calculus of the Kidney, 219; of 
Spermatorrhoea, 220 ; of Gonorrhoea, 220. 

Dl-HYDROGEN SOMUM PHOSPHATE, . . . .62 

DlSTOMA HAEMATOBIUM, ..... 135 

Disulphonic Acid. — See Xanthin, . . . .55 

Donne's Test for Pus, ..... 119 

Ductus Papillaris, . . . . . .10 

Echinococci — With Pyelitis, .... 196 

Edlefsen on Globulin in Amyloid Kidney, . . 186 

Efferent Passages, ..... 15 

Entozoa — Occurrence of Parts Entozoa, of Hooklets of 
Echinococci, 134; Haematuria Caused by Them, 134; 
Distoma Haematobium, Bilharzia Hsematobia, 135. 
Epithelia — In Gonorrhoea, ..... 220 
Epithelial Tubes — In Acute Yellow Atrophy, 170 ; in 

Desquamative Nephritis, 178. 
Epithelial Tubes and Casts — Origin ; Varieties ; Gen- 
eral Appearance, 126. 
Epithelial Cells— Source of, in Urine, 115; Forms, 115. 
Round — Their Origin, Form, and Characteristics, 115; 
their Resemblance to Pus Cells, and How to Distin- 
guish between Them, 116 ; their Preservation in Acid 
and Alkaline Urine, 116 ; How to Distinguish be- 
tween Epithelium from the Male Urethra and from 
the Kidney, 116; Epithelium from the Prostate, 
Cowper's, and Littre's Glands, 116. 
Conical and Cells with Processes — Their Origin and 

Form, 117. 
Flat — Their Origin, Form, and Characteristics, How 
to Distinguish between Epithelium of the Bladder 
and that of the Vagina, 117 ; Yellow Discoloration 
of Epithelial Cells in Jaundice, 118. 



INDEX. 233 

PAGE. 

Epitheliomata — Symptoms Caused by, . . . 213- 

Epithelium — Bladder, in Bilharzia Haematobia r 196; in 
Hemorrhages from the Bladder, 202 ; in Cysto-Pye- 
litis, 106 ; in Pyelo-Cystitis, 206 ; in Chronic Catarrh 
of the Bladder, first degree, 208 ; in Chronic Catarrh, 
third degree, 211. 
Hemorrhagic, in Haemoglobinuria, 197; in Parenchym- 
atous Hemorrhages, 201. 
Kidney, in Hypenemic Kidney Proper, 177; in Chronic 
Parenchymatous Nephritis, 181 ; in Hyperplastic In- 
terstitial Nephritis, 183; in Suppurative Interstitial 
Nephritis, 181 ; in Amyloid Kidney, 186 ; in Acute 
Pyelitis, 189; in Pyelitis Tuberculosa, 191; in Bil- 
harzia Hasmatobia, 196; in Parenchymatous Hemor- 
rhage, 201 ; in Nephrophthisis, 203; in Cysto-Pyelitis, 
206; in Pyelo-Cystitis, 206. 

Examination of Urine — Order to be Followed in the 
Chemical, Nitric Acid Test, Method of Applying, 
and List of Substances to be Detected by It, 159, 160 

Test by Boiling, Method of Procedure, and Substances 

to be Detected by It, .... 160, 161 
Test for Normal Coloring Matter of Urine . . 161 

Test for Normal Inorganic Salts, .... 161 
Test for Abnormal Substances, . . . 162 

Examination of the Sediment, Method of Procedure, 
etc., . . . . . . .162 

Exanthemata — Albumin in, . . . . 175 

Exudations — "Which Prevent the Flowing Back of Ven- 
ous Blood, their Effect on the Kidney, . .176 

Fat — Occurrence of, 108, 109 ; Occurrence of Emulsified 
Fat, 109; Appearance Under the Microscope, 109. 

Febrile Condition — Urine Indicating a, 168; Diagnosis, 
169. 

Feiii.ixg's Method for Estimation of Sugar, . . 153 

Solution and How to Prepare and Preserve It, 153, 154 

Fermentation in Urine — Description of So-Called, 96; 



234 INDEX. 

Fermentation in Urine — pagk. 

Description of Alkaline, 97 ; Process of Alkaline Fer- 
mentation, 97 ; Museulus' Discovery, 97 ; Cause of 
Acid Fermentation, 97 ; Cause of Alkaline Fermen- 
tation, 97; Sediment of Alkaline Urine, 98; Presence 
of Bacteria, 98. 
Fever — The Urine of, its General Appearance and Char- 
acteristics, its Characteristics in the Presence of an 
Exudative Process, in the Stage of Absorption, 168. 
Fibrin — When Found, . . . . .67 

Coagula, in Bilharzia Hgematobia, . . . 196 

Fibrinuria — In Papillary or Vascular Tumors, its Urine 

and Cause, ..... 215, 216 

True, Occurrence of, . . . . . 67 

Fungi, ...... . 128, 131 

Bacteria, ...... 128, 129 

Oidium Lactis, . . . . . .130 

Spores and Fragments of Penicillium Glaucum, . 1 30, 131 
Sarcinae, ....... 130 

Yeast Fungus, . . . . .129,130 

Galacturia, ....... 109 

Globulin, 74; in Amyloid Kidney (Senator, Edelfsen), 

186. 
Glomerulus, . . . . . . .10 

Glycol Combinations, ..... 94 

Gmelin's Test for Biliary Coloring Matter, . . 87 

Gonorrhoea — Its Urine; Threads of, . . . 220 

Gout — Urine of, . . . . . 172 

Graham, ....... 66 

H^matinuria, . . . . . .86 

H^ematoidin, ...... 133 

In Sediment of Urine from Papillary or Vascular 

Tumors, . . . . . . .218 

HEMATURIA, . . . . . . 132 

Asa Symptom, 196; Origin of, 198; Diagnosis of, 198, 
202 ; in Vescical Calculus ; in Catarrhal Ulcers, 204. 



INDEX. 235 

PAGE. 

Haemoglobin. — See Blood Coloring Matter, . . 84 

In Haemoglobinuria, 197 ; in Parenchymatous Hemor- 
rhage, 197. 

Hemoglobinuria (Haeniatinuria of Vogel), . . 197 

Its Urine, ...... 197 

Diseases in which it Occurs, .... 202 

Heavy Metals — Occurrence of, . . . . 94 

Hemorrhage — Copious, Pr6duced by Rupture of Large 
Blood-Vessels, 197, 198; Urine of, 198 ; Occurrence, in 
Tumors, in Diphtheritic and Croupous Processes of 
the Bladder, Characteristics with these Diseases, 205. 

Hemorrhages — Parenchymatous, in the Presence of Large 
Concretions, 192 ; in Bilharzia Haematobia, 196. 

Heller — On Ammonium Carbonate, . . .93 

On Sarcinse, ...... 172 

On Uroerythrin, . . . . . .82 

Heller's Urrhodin, ..... 47 

Heller's Tests for Biliary Coloring Matter, 87 ; for 
Sugar, 76. 

Hippuric Acid — Where Found, Relative Quantity of, 
Reaction with Hydrochloric Acid, when Quantity is 
much Increased, 55. 
Quantity of, as Affected by the Administration of Ben- 
zoic and Hippuric Acid, 55 ; by Diabetes and Febrile 
Diseases, 55; by Meat Diet, 55; by Eating Certain 
Kinds of Fruit, 55; in Leucaemia, 173. 

Hoffmann's Tyrosin Test, . 105 

Hydrogen Di-Sodium Phosphate, ... 62 

Hydrogen Bi-Sulphide— Occurrence of, 93 ; Test for, 93. 

Hydruria — Urine of, .... 167, 172 

Icterus Gravis — Urine of, . . . .170 

Icterus Levis— Bile and Chlorides in, . . . 169, 170 

Lndican — In Peritonitis, 170; in Meningitis Spinalis, 171; 

in Hysteria, 171; in Diabetes Mellitus, 172; in 

Chronic Diseases of the Spinal Cord, 172. 



236 INDEX. 

PAGE. 

Inosit, ........ 80 

Intermittens — Urine of, . . . . . 173 

Iron, . . . . . . . . 65 

Jaundice — Urine of, .... . 169, 170 

Kidney — Amyloid,, its Significance, Predisposing Causes, 
Occurrence, Symptoms, 185. 
Appearance of Sections of, 7; Description, 7; Papilla, 
Papillary Zone, Boundary Zone of the Medulla, Cor- 
tical Layer, Medullary Eays, Labyrinth, Stroma, 8. 
Blood-Vessels of, their Origin, and Termination, and 
Branches, 13; Course of the Veins, 13, 14; Venous 
Trunks, Veins of the Medulla, of the Capsule, 13, 14. 
Calculus of the, Cause of, . . . . . 175 

Cirrhosis of the, ..... 182 

Contracted, ....... 182 

Disease as a Complication of Chronic Diseases of the 
Liver, ....... 173 

Hemorrhages from, Diseases in which They are Ob- 
served, 203 

Hyperemia of the, Active, 174 ; its Urine, 174, 176 ; its 

Cause, 175. 
Hyperemia of the, Passive, its Occurrence, . . 176 

Hypersemic, when Found, .... 176- 

Nerves, their Derivation, Course, and Termination, 14, 15 
Pelvis of, . . . . . . .15 

Koch's Discovery an Aid to the Diagnosis of Tubercular 

Processes, ...... 195 

Knapp's Method of Estimating Sugar, . . . 155 

Knop-Hufner's Method of Estimating Urea, . . 148, 149' 

KpvEatinin — Quantity of, as Affected by Animal and 
Vegetable Diet, 55; by Inanition, 55; by Intermit- 
tens, 55 ; by Advanced Disease of the Kidney, 55 ; 
by Pneumonia, 55 ; by Typhus, 55. 
Klebs — On Nephritis Parasitica, 127 ; on Pyelo-Nephritis 
Parasitica, 184. 



INDEX. 



237 



Kyestein. 



PAGE. 

131 



Lactic Acid — Its Presence in Normal Urine, when Found 

in Pathological Urine. .... 56 

Leucaemia — Urine of, ..... 173 

Lectin and Tyrosin — Appearance Under the Micro- 
scope. 107: Occurrence of Tyrosin, 107; How to Dis- 
tinguish Leucin from Fat, 107, 108 ; Piria's Test for 
Tyrosin. 10S ; Hoffman's Test for Tyrosin, 10S. 
Formula? for, 80; Origin of, and When and Where 
Found. 80, 81; Methods for Detection. 81; Signif- 
icance of. SI. 
In Acute Yellow Atrophy of the Liver, . .170 

Liebig's Method for Estimation of L^rea, . . 144, 148 

Liver — Chronic Diseases of the Urine of, . . . 173 

Lithiasis — Symptoms of, in Pyelitis Tuberculosa, . 194 

Ludwict — Theory of Osmosis. . . IS. 19, 66, 67 

Lungs — Chronic Diseases of, their Effect on Kidney, . 176 
Lymph Corpuscles — In Desquamative Nephritis, 17S: in 
Acute Parenchymatous Nephritis. 179. 



Malacosteon — Urine of, . . . .172 

Malphigian Capsule — Its Wall?, its External Surface or 

Tuft. Tunica Propria, 11, Epithelium, Epithelial 

Pulp. 12. 
Marasmus — As a Cause of Hyperaemic Kidney, . .176 

Melan\emia, . . . . . .173 

Meningitis — L>ine of. .... 170. 171 

Mesoxalic Acid — Its Origin, .... 56 

Meth.emoglobin. — See Blood Coloring Matter, . . 84 

In Hemoglobinuria, ..... 197 

[Metallic Bases. . . . . . .94 

Metals — Heavy, Occurrence of, ... 94 

Mi< k<»ccus Ure.e — Appearance of, . . . .97 

Microcytes — In Parenchymatous Hemorrhage, . 198 

Mineral A . . . . . .94 

E. C 



238 INDEX. 

PAGE. 

Mohr — Estimation of Chlorine, . . . 155 

Mulder— Test for Sugar, . . . . .77 

Museums' Discovery of Ferment Test for Urea, . 97 

Mucus— How to Detect, 114; Appearance Under the Mi- 
croscope, 114 ; Mucus in Women, 114 ; how to Sepa- 
rate it from Urine, 115. 
In Desquamative Nephritis, 178; in Cystitis, 207; 
in Acute Catarrh of the Bladder, first degree, 208; 
in Acute Catarrh, second degree, 209; in Chronic 
Catarrh, third degree, 211. 
Myosin, . . . . . .74 

Nubecula, ....... 31 

Nephritis — Desquamative, Symptoms of, 177 ; Urine of, 
178. 
Interstitial, ....... 182 

Hyperplastic Interstitial, 182 ; Occurrence, 182 ; Symp- 
toms and Complications, 183 ; its Urine, 182. 
•Suppurative Interstitial, its Origin, 183; Predisposing 

Conditions; its Urine, 184; its Course, 185. 
Parenchymatous, Causing Puerperal Convulsions (Bar- 
tels), . . . . . . .176 

Parenchymatous, Chronic, 180 ; Symptoms of, its Ori- 
gin, Causes and Course, 181, 182; its Urine, 180; in 
the Stage of Secondary Atrophy, 181. 
Parenchymatous, Acute, Symptoms of, Urine, . . 179 

Nature of the Disease, Occurrence, Causes, . . 180 

Nephrophthisis, ...... 203 

Nitrogen — Estimation of Total, . . . 157 

Neukman, ....... 80 

His Modification of Pettenkofer's Test for Biliary Acid, 91 

Odor — Of Fresh Normal Urine, of Urine which has Stood, 

of Abnormal Urine, . . . . .32 

As Affected by Eating Asparagus and Cauliflower, after 
Turpentine, . . . . . .32 



INDEX. 239 

Odor — page. 

In Suppurative Interstitial Nephritis, 1S4 ; in Cystitis, 
207 ; in Chronic Catarrh of the Bladder of the first 
degree, 208; in Chronic Catarrh (third degree), 211; 
in Medullary Sarcomata, 213. 

Oidium Lactis — Construction, Characteristics, and Oc- 
currence, ....... 130 

Oliguria — Diagnosis of, . . . . . 167 

Occurrence and Causes of, .... 168 

Oxalic Acid — Where Found and in what Form, . 56 

OxYMAXDELIC ACID, . : . . . .82 

Paranephritis — See Perinephritis, . . . 196 

Parenchymatous Hemorrhage, 197; Urine of, 197; Dis- 
eases in which it Occurs, 202, 204, 205 ; in Papilloma 
and Villous Carcinoma of the Bladder, 204. 

Pasteur — On Micrococcus Urea?, 

Pemphigus, . . . . . . * 

Penicillium Glaucum — Their Condition, Appearance 
and Origin, 130 ; their Occurrence and Possible Con- 
nection with Fermentation, 130; in Diabetic Urine 
172. 

Pepton — When Found, .... 

Pericarditis — Urine of, . 

Perinephritis — Urine of, .... 

Peritonitis — Urine of, . 

Pettenkofer's Test, ...... 

Phosphates — Average Quantity, 

Alkali — Proportion of, 62 ; to Determine the Quantity 

62, 63. 
Alkali — In the Presence of an Exudative Process, 
Magnesium — 60; Occurrence, Appearance, How to Dis- 
tinguish, 111, 112. 
Earthy — Amorphous, Occurrence, 109; Appearance 
Under the Microscope, Differentiation from Urates, 
Causes, Precipitation, Admixture of Triple Phos- 
phate, 110. 



173 



74 

171 

196 

170 

90 

59 



168 



240 INDEX. 

Phosphates — page. 

Earthy — The Qauntityof, as Affected by Exclusive (not 
constant) Meat Diet, by Diseases of Bone, by Diseases 
of the Kidneys, by Malacosteon, by Medicines, by 
Introduction of Mineral Waters Rich in Calcium, 
by Extensive Peritonitis, by Rachitis, by Chronic 
Arthro-Rheumatic Processes, 62. 

Earthy — Condition of, in Acid and Alkaline Urine, 60 ; 
Effects of Abnormal Coloring Matter on Precipitates 
of, 61 ; Average Quantity, 60 ; Reaction for Soluble 
Earthy, 61 ; Tests for, 61 ; to Withdraw Acid from 
Calcium and Magnesium Phosphate, 61. 

Earthy — In the Urine of Fever, in the Stage of Absorp- 
tion, 169 ; in Meningitis, 171 ; in Acute Articular 
Rheumatism, 171 ; in Rickets, 172 ; in Malacosteon, 
172 ; in Chronic Rheumatic Arthritis, 172 ; in Chronic 
Disease of the Liver, 173; in Pyelitis Calculosa, 191;, 
in Acute Catarrh of the Bladder of second degree, 
20y ; in Chronic Catarrh of third degree, 211 ; in 
Catarrh of the Bladder, 212 ; in Spasm of the Blad- 
der, 212 ; in Spermatorrhoea, 219. 

Triple — Appearance, 112; Form, 113; How to Differen- 
tiate from Salt, 113. 

Triple — In Hemorrhage from the Bladder, 202; in Cysto- 
Pyelitis, 206 ; in Pyelo-Cystitis, 206 ; in Acute Catarrh 
of the Bladder (first degree). 208; Spasm of the 
Bladder, 212. 
Phosphoric Acid —Chemical Characteristics of, 60 ; Posi- 
tion in Urine, 60. 

Three Alkali Salts — Their Formation, 62 ; Di-Hydrogen 
Sodium Phosphate, Hydrogen Di-Sodium Phosphate, 
and Tri-Sodium Phosphate, 62. 

Estimation of, ..... 157 

Three Salts with Calcium — Their Formation, the Neu- 
tral, the Single Acid, and the Double Acid Salt, 60, 61 

PlCNOMETER, . ..... 24 

Piria's Tyrosin Test, . . " . ' . . 108 



INDEX. 241 

PAGE. 

Polyps — Fibrous. Symptoms Caused by, . . . 213 

Polyuria — Diagnosis of, Physiological or Pathological, 167 
Pregnancy — Its Effect on the Kidney, . . .176 

Prognosis— Of Acute Parenchymatous Nephritis, 180; of 
Chronic Parenchymatous Nephritis, 182 ; of Hyper- 
plastic Interstitial Nephritis, 183 ; in Suppurative 
Interstitial Nephritis, 185 ; in Amyloid Kidney, 186 ; 
Acute Pyelitis, 190 ; of Chronic Pyelitis, 191 ; of 
Pyelitis Calculosa, 193; of Pyelitis Tuberculosa, 195 ; 
of Cysto-Pyelitis, and Pyelo-Cystitis, 206; of Papil- 
lary or Vascular Tumors, 214. 
Prostate Gland — Diseases of, Complications of, . . 219 

Pulmonary Affections — Acute, Urine of, . . 170 

Pus Corpuscles— Characteristics, 118; Form, 118; Changes 
which Pus Corpuscles Undergo in Alkaline Urine, 
and their Cause, 118; How to Distinguish between 
Pus Corpuscles in Alkaline Urine and Albumin and 
Mucus, 118. 119 ; Number of Pus Corpuscles, 119 ; 
Method of Differentiation between Pus Corpuscles 
and the Phosphates, 119; Donne's Test for Pus, 119. 
Pus — In Suppurative Interstitial Nephritis, 184 ; in Acute 
Pyelitis, 189; in Chronic Pyelitis, 190; in Pyelitis 
Calculosa, 192 ; in Pyelitis Tuberculosa, 194 ; Cor- 
puscles, in Bilharzia Ha?matobia, 196 ; in Cysto- 
Pyelitis, 206 ; in Pyelo-Cystitis. 206 ; in Cystitis, 207 ; 
in Acute Catarrh of the Bladder (sesond degree), 209 ; 
in Chronic Catarrh (third degree), 210; in Acute 
Catarrh of third degree, 210; in Chronic Catarrh of 
third degree, 211 ; in Spasm of the Bladder, 212; in 
Epitheliomata, 213 ; in Papillary and Vascular Tu- 
mors, 215 ; in Papillary and Vascular Tumors, 216 ; 
in Gonorrhoea, 220. 
Pyelitis — Occurrence, Causes, Diseases which it Al- 
ways Accompanies, its Different Forms and their 
Causes, ....... 188 

In Echinococci, in Bilharzia Hsematobia, . . 196 



242 INDEX. 

Pyelitis — page. 

Acute, Occurrence, ..... 188 

Calculosa, its Origin, Mild and Severe Forms, Urine 
of Mild Form, ..... 192 

Pyelitis (Chronic) — Characteristics, 190 ; Complications, 
Course, Termination, 191. 

Pyelitis Tuberculosa — What it Indicates, 192 ; Compli- 
cations, 192 ; Koch's Test for Tuberculosis, 195. 

Pyelo-Cystitis — Nature of the Disease, 205; Occurrence, 
206; Origin, 206. 

Pyelonephritis Parasitica (Klebs), . . . 184 

Pyorrhea, . . . . . . . 187 

Quantity — Average, Variation in, . . . .23 

As Affected by Cold, by Profuse Diarrhoea, by Taking 
Large Quantities of Fluids, by Moisture, Profuse 
Perspiration, by Eest, .... 23 

Quantity of Urine Excreted — In Hysteria, 171 ; in In- 
termittens, 173 ; in Hyperemia of the Kidney, 176, 
177; in Desquamative Nephritis, 178; in Acute 
Parenchymatous Nephritis, 179; in Chronic Paren- 
chymatous Nephritis, 181 ; in Hyperplastic Intersti- 
tial Nephritis, 183 ; in Amyloid Kidney, 185 ; in 
Acute Pyelitis, 189; in Chronic Pyelitis, 190; in 
Mild Pyelitis Calculosa, 192 ; in Pyelitis Tuberculosa, 
194; in Cysto-Pyelitis and Pyelo-Cystitis, 206; in 
Acute Catarrh of the Bladder (first degree), 208; in 
Chronic Catarrh of the Bladder (first degree), 208 ; in 
Acute Catarrh (second degree), 209; in Papillary or 
Vascular Tumors, 215. 

Keaction — Cause of Normal Acid, 33 ; Acid Changed to 
Neutral or Alkaline, 33 ; Importance of Great Acid- 
ity, 33 ; Causes of Alkalinity, 34 ; Amphoteric, 34. 

Reaction of Urine— In the Presence of an Exudative 
Process, in the Stage of Absorption, 168; in Acute 
Yellow Atrophy, in Meningitis, 170 ; in Typhus, in 



INDEX. 243 

Reaction of Urine — page. 

Acute Articular Rheumatism, 171; in Chronic 
Rheumatic Arthritis, 172 ; in Chronic Diseases of 
the Liver, 173 ; in Hyperemia of the Kidney, 175, 
176; in Desquamative Nephritis, 178; in Acute 
Parenchymatous Nephritis, 179 ; in Chronic Paren- 
chymatous Nephritis, 181 ; in Hyperplastic Intersti- 
tial Nephritis, 183; in Suppurative Interstitial Ne- 
phritis, 184; in Acute Pyelitis, 189; in Chronic 
Pyelitis, 190 ; in Renal Calculi, 191 ; in Mild Pyelitis 
Calculosa, 193 ; in Pyelitis Tuberculosa, 194 ; Hemo- 
globinuria, 197; in Parenchymatous Hemorrhage, 
197 ; in Hemorrhage from the Rupture of Large 
Vessels, 198 ; in Cysto-Pyelitis, 206 ; in Pyelo-Cys- 
titis, 206 ; in Cystitis, 207 ; in Acute Catarrh of the 
Bladder (first degree), 208 ; in Chronic Catarrh, first 
degree, 208; in Acute Catarrh (second degree), 209 ; 
in Chronic Catarrh (second degree), 210; in Spasm of 
the Bladder, 212 ; in Papillary and Vascular Tumors, 
215 ; Calculi of the Bladder, 219 ; in Spermatorrhoea, 
219. 
Rheumatism — Acute Articular, Urine of, - . . 171 

Rickets, Urine of, ..... 172 

Saccharomyces Urix.e — Their Character, Size, Shape 
and Arrangement, 129; their Number and Occur- 
rence, 130. 
Sarctx.e — Their Appearance, Arrangement and Occur- 
rence, ....... 130 

Sarcomata — Medullary, Symptoms and Urine of, . 213 

Schwanert — On Estimation of Uric Acid, . . . 150 

Scorbutus — Urine of, . . . .173 

Sediments — 95, 141 ; Classification of, 98 ; Table of Classi- 
fication, 99. 
In Acute Articular Rheumatism, 171; in Diseases of 
the Bone, 172; in Chronic Diseases of the Liver, 
173; in Hyperemia of the Kidney, 176; in Des- 



244 INDEX. 

Sediments — • page. 

quamative Nephritis, 178 ; in Acute Parenchyma- 
tous Nephritis, 179; in Chronic Parenchymatous 
Nephritis, 181 ; in Hyperplastic Interstitial Nephritis, 
183; in Suppurative Interstitial Nephritis, 184; in 
Amyloid Kidney, 185, 186; in Acute Pyelitis, 189; 
in Chronic Pyelitis, 190; in Pyelitis Calculosa, 192, 
193; in Pyelitis Tuberculosa, 194; in Parenchyma- 
tous Hemorrhage, 197 ; in Hemorrhage from the 
Eupture of Large Vessels, 198, 201 ; in Cysto-Pye- 
litis, 206; in Pyelo-Cystitis, 206; in Cystitis, 207; 
in Acute Catarrh of the Bladder (first degree), 208; 
in Chronic Catarrh of first degree, 208, 209 ; in Acute 
Catarrh (second degree), 209; Chronic Catarrh (sec- 
ond degree), 210; in Acute Catarrh (third degree), 
211 ; in Chronic Catarrh (third degree), 211 ; in 
Spasm of the Bladder, 212 ; Medullary Sarcomata, 
213 ; in Epitheliomata, 213 ; in Papillary and Vas- 
cular Tumors, 215 ; in Hypertrophied Prostata, 219. 
Non-Organized — Ammonium Urate, 101 ; Calcium Car- 
bonate, 113; Calcium Oxalate, 104; Cystin, 105; 
Earthy Phosphates, 109; Fat, 108; Leucin and 
Tyrosin, 107 ; Magnesium Phosphate, 111 ; Triple 
Phosphate, 112; Urates, 99; Uric Acid, 102. 

Senator — Globulin in Amyloid Kidney, . . . 186 

Serum Albumin — In Acute Parenchymatous Nephritis, 
179; in Amyloid Kidney, 186. 
Condition of Normal Urine in which it Occurs, 66; 
Occurrence of, 65; Explanation of its Presence in 
Normal Urine, 66. 

Specific Gravity — Determination of, to Determine by 
Means of Urinometer, Significance of High and 
Low, 23, 24 

Specific Gravity of Urine — In Acute Yellow Atrophy, 
170 ; in Meningitis, 170, 171 ; in Acute Articular 
Eheumatism, 171 ; in Chlorosis, 171 ; in Diabetes 
Mellitus, 172; in Hyperemia of the Kidney, 176, 



INDEX. 245 

Shecific Gravity of Urine — page. 

177; in Desquamative Nephritis, 178 ; in Acute Pa- 
renchymatous Nephritis, 179; in Hyperplastic In- 
terstitial Nephritis, 1S3 ; in Suppurative Interstitial 
Nephritis, 184; in Amyloid Kidney, 185; in Acute 
Pyelitis, 189 ; in Chronic Pyelitis, 190 ; in Mild Pye- 
litis Calculosa in Pyelitis Tuberculosa, 194; Hae- 
meoglobinuria, 197; Hemorrhage from the Rupture 
of Large Vessels. 198-200 ; in Cysto-Pyelitis, 206 ; in 
Pyelo-Cystitis, 206; in Chronic Catarrh of the Blad- 
der of the first degree, 208; in Acute Catarrh (second 
degree), 209; in Papillary or Vascular Tumors, 215. 
Silicic Acid. — See Note, . . . . .65 

Solids — Quantity of, in Twenty-four Hours, 25 ; its Great 
Significance, 27 ; Approximate Determination of 
Quantity. 25, 26 ; Estimation of Total, 144. 
Spermatorrhoea — Its Urine, .... 219, 220 
Spermatozoa — Their Appearance, Under the Microscope, 
of Urine Containing Sperm, 131; their Occurrence. 
132. 
In Hypertrophy of the Prostate Gland, 219; in Sperm- 
atorrhoea, 219. 
Spinal Cord — Chronic Diseases of, Urine of, . .172 

Strassburger's Test for Biliary Acid, ... 90 

Sugar — Occurrence of, 56, 75, 80; Formula for, 75: Crys- 
tallization. 75; Briicke on, 75, 78; Heller's, Mulder's. 
Trommer's, and Boettger's Test's for, 76, 77; Note on 
Heller's Test. 76, 77 : Biidecker on Tests for, 76, 77 ; 
Comparative Value of Tests, 78 ; Methods for Ap- 
proximate Determination of Quantity, 79 ; Estima- 
tion of, 153. 
Methods of Approximate Determination of Quantity, . 79 
In Chronic Diseases of the Spinal Cord, . . 1 72 

Sulphates — The Quantity of, as Affected by Exclusive 
Meat or Vegetable Diet, Acute Febrile Diseases 
Accompanied by Free* Excretion of Urea, Introduc- 
tion of Sulphuric Acid or of Sulphur in any Form. 



246 INDEX. 

Sulphates — page. 

in the Beginning of Typhus, 65 ; in the Urine of 

Fever, in the Process of an Exudative Process, 168. 
Found in Urine, 63 ; Reaction, 63 ; Relative Quantity 

of Sodium Sulphate, 63. 
Sulphuric Acid — Average Quantity, 63 ; Reaction, 63 ; 

Vogel's Quantitative Test, 64 ; Estimation of, 158. 

Tests — For Albumin, 68, 71; Ammonium Carbonate, 92; 
Ammonium Urate, 102 ; Biliary Coloring Matter, 
Changed, 89; Biliary Coloring Matter, 87; Blood 
Coloring Matter, 85; Calcium Carbonate, 113; Cal- 
cium Phosphate, Crystallized, 111; Cystin, 106; 
Hydrogen Bi-Sulphide, 93; Iodine, 95; Leucin and 
Tyrosin, 108 ; Magnesium Phosphate, 111 ; Metallic 
Bases, 94 ; Phosphates, 62 ; Phosphates, Earthy, 110 ; 
Pus, 119; Salicylic Acid, 95; Sodium Chloride, 58; 
Sugar, 76; Sulphates, 63; Urates, 100; Urea, 37, 97; 
Uric Acid, 44 ; Uric Acid Casts, 127 ; Urine Indican, 
52 ; Urobilin, 50 ; Xanthin, 55. 

Tests — Quantitative, for Acidity, 143 ; Chlorine, 156 ; 
Creatinin, 151 ; Nitrogen, 151 ; Phosphoric Acid, 
157; Sugar, 153; Sulphates, 64; Urea, 145. 

Tissue — Necrotic Papilla, in Papilloma and Villous Car- 
cinoma of the Bladder, 204. 

Tri-Sodium Phosphate, . . . . .62 

Trommer — Test for Sugar, .... 77 

Tumors — Ovarian, their Effect on the Kidney, . . 176 

Papillary or Vascular, 214 ; Urine, 215 ; Symptoms, 218 ; 
Microscopic Examination of Urine in, 216, 218; 
Papillary Proliferations of the Mucous Membrane 
of the Bladder, Accompanying Diseases, 214. 

Tyrosin.— See Leucin and Tyrosin, . . 80, 82, 107, 108 

In Acute Yellow Atrophy of the Liver, . .170 

Ultzman's Test, . . •. . . .88 

Composition of Calculi from the Bladder, . 138 



INDEX. 247 

PAGE. 

Ukates — Occurrence in Urine, 99 ; Solubility of, 100 ; 
Conditions Favorable to the Formation of a Sedi- 
ment of Urates, 100; Appearance of the Alkali 
Urates, 100 ; Method of Differentiation between 
Urates and Pus and the Phosphates, 100, 101 ; Mu- 
rexid Test, 101 ; Microscopic Test, 101. 

In the Urine of Fever, 168; in the Stage of Absorp- 
tion, 169; in Jaundice, 170; in Acute Yellow 
Atrophy of the Liver, 170 ; in Meningitis, 170 ; in 
Meningitis, 171; in Acute Articular Rheumatism, 
171 ; in Chronic Rheumatic Arthritis, 172; in Chronic 
Diseases of the Liver, 173 ; in Febrile Albuminuria, 
176, 177; in Acute Pyelitis, 189; in Pyelitis Calcu- 
losa, 191, 193. 
Urea — Estimation of, 144 ; Appearance of, 36 ; Chemical 
Characteristics, 36 ; Decomposition, 37 ; to Detect, 
39 ; Determination of, 39 ; Approximate Determina- 
tion of, in the Presence of Albumin, 40; by the 
Specific Gravity of the Urine, 39 ; Discovery of, by 
Rouelle, the younger, 4; Microscopic Examination 
of, 36 ; Origin of, 41 ; Obtained from Protein, 41 ; to 
Obtain by Simple Methods, 36 ; to Obtain Synthet- 
ically, 36 ; Presence of, in the Absence of Chlorides,. 
39 ; Proportion of, in Presence of Sugar, 40 ; Propor- . 
tion of, as Influenced by the Quantity of other Sub- 
stances Present, 39, 40; as a Measure of Tissue 
Change, 41. 

Quantity of, as Affected by Cachexias, 42 ; by Diabetes 
Mellitus and Insipidus, 42 ; by Animal Diet, 41 ; by 
Vegetable Diet, 42; by Fasting, 42; by Acute Febrile 
Diseases, 41 ; by Parenchymatous Affections of the- 
Kidney, 42 ; by Urina Spastica, 42 ; by Urina Potus, 42. 

In the Urine of Fever, in the Presence of an Exuda- 
tive Process, 168 ; in Acute Yellow Atrophy of the 
Liver, 170; in Acute Articular Rheumatism, 171; 
in Chronic Parenchymatous Nephritis, 181 ; in Sup- 



248 INDEX. 

UREA PAGE. 

purative Interstitial Nephritis, 184; in Pyelitis Cal- 
culosa, 191 ; in Acute Catarrh of the Bladder (second 
degree), 209. 
Reaction, with Mercuric Nitrate, 37 ; with Oxalic Acid, 
38 ; with Nitric Acid, 38; Nitric Acid Test for, 39. 
Ureters — Their Structure, Muscular Layer, . . 15 

Urethra— (Male), Description, Structure, Epithelium, 17; 
(Female), Structure, 17. 
Diseases of, Complications of, 219 ; Croup of, 220. 
Uric Acid. — Appearance of Free, 45; in Sediment, 45; 
Chemical Characteristics, 45 ; Crystalline Form, 43 ; 
Approximate Determination, 48, 49 ; to Obtain from 
Urine, 43; Effects of Oxidizing Agents upon, 45; 
Effects of Ozone upon, 45; Presence of, in Urine, 43; 
Solubility, 42. 
Cause of its Occurrence, 102 ; Primary Form of, 103 ; 
Other Forms of, 103 ; Occurrence of the Rough, and 
the Lance-Shaped Forms of, 103; Appearance of 
Urine Containing Uric Acid, 104 ; Estimation of, 149. 
Quantity of, as Affected by Arthritis, 47 ; by Diabetes 
Mellitus, 47 ; by Diseases where the Functions of 
the Diaphragm are Interfered with, 47 ; by Uric Acid 
Diathesis, 47 ; by Acute Febrile Diseases, 47 ; by the 
Amount of Food Taken, 47 ; by Diseases of the Heart 
and Lungs, 47 ; by Hydruria, 47 ; by Chronic Kidney 
Diseases, 47 ; by Leucaemia, 47 ; by Tumors of the 
Abdomen, Ascites, etc., 47; by Urina Spastica, 47. 
Uric Acid Salts — Appearance in Sediment, 42; Chem- 
ically Considered, 46; Comparative Solubility of, 
45, 46 ; Source of, 46 ; when Great Increase of is 
Found, 47. 
Tests for — To Test Concrements for, 44; Glacial Acid 
Test for, 44 ; Nitric Acid Test for 44. 
Urina Potus, ■.-■'. . . . . . 167 

Urina Spastica, ...... 167 



INDEX. 



249 















PAGE. 


Urinalysis — History of, Andral, 






5 


Avicenna, 












3 


Becquerel, 














5 


Bellini, Lorenzo, 














4 


Brandt, .... 














4 


Bright, 














4 


Cotugno, . 














4 


Cruikshank, . 














4 


Galen, .... 














3 


Hippocrates, . 














2 


Iben Sina, 














3 


Johannes, called Actuarins, 














3 


Markgraff, 














4 


Pront, .... 














5 


Rayer, .... 














5 


Rouelle, the Younger, 














4 


Scheele, .... 














5 


Wetzlar, 














5 


Willis, .... 














4 


Wollaston, 








5 


Urinary Apparatus — Histology of the 


Kidney, 7 ; U 


rin- 




iferous Tubules, 9 ; Blood Vessels o 


f the Kidney, 


13; 




Efferent Passages, Ureters PelYis o 


f the Kidney 


and 




Calyces, 15 ; the Bladder, 15 ; Male 


Urethra and 


Fe- 




male Urethra, 17. 








Urine — Examination of, its Value in G 


reneral Diagn< 


3sis, 


166- 


Urine — Physical Properties of, Color, 




. 29, 


31 


Consistency, 




28 


29 


Fluorescence. — See Transparency, < 


?tc, . 




31 


Odor, . 






32 


Quantity, 




. 23, 


167 


Reaction, .... 




33 


34 


Solids, .... 




. 25, 


27 


Specific Gravity, 




23, 


24 


Transparency and Fluorescence, 






31 


Turbidity, .... 












31 


32. 



250 



INDEX. 





18 




21 


19 


20 




20 


20 


21 


19, 


20 


18, 


19 




21 




21 




21 




20 


20, 


21 



Urine — Secretion and JSxcretion, Bowman's Theory, 
Donath, .... 
Goll's Theory, . . 

Griitzner's Theory, 
Heidenhain's Theory, . • 

Hermann's, Max, Theory, 
Ludwig's Mechanical Theory, 
Maly, .... 

Mnller's, K., Experiments, . 
Posch, .... 

Ustimowitsch's Theory, 
Wittich, .... 

Uriniferous Tubule — Origin, its Course, Direction and 
Form, Malphigian Capsule, Henle's Loop, Collecting 
Tubule, 9; Ductus Papillaris, 10. 

Urine Indican — Chemical Characteristics, 52 ; How to 
Obtain, 51 ; Heller's Eesearches, 51 ; Source of, 54 ; 
Heller's Urophaein and Uroxanthin, Tests for, 52, 
53 ; Jaffe's Test, 53 ; Stokvis Test, 54 ; Quantity of 
as Affected, Albumin of Food and Tissues, 54; by 
Cancer of the Liver and Stomach, 54; by Chronic 
Consumption, 54; by Constipation, 54; by Meat 
Diet, 54 ; by Addison's Disease, 54 ; by Acute Dis- 
eases Generally, 55 ; by Fever, 55 ; by the Introduc- 
tion into the System, 54 ; by Diseases which Produce 
a Closure of the Small Intestine, 54 ; by Ligation of 
the Small Intestine, 54; by iVing the Intestine in 
the Last Stage of Panereas Digestion, 54; by Inani- 
tion-Processes, 54; by Granular Kidney, 54; by 
Lesions of the Central and Peripheral Nervous Sys- 
tems, 55; by Obstruction of the Large Intestine, 54; 
by Peritonitis, 54. 

Uriniferous Tubules. — Catarrh of 178 

Its Origin and Causes, .... 178, 179 

Urinometer, ...... 24 



INDEX. 



251 



Urobilin — Color, 49; Detection of, 50: What it Indi- 
cates. 50; Maly's Views. 50; How to Obtain, 49, 50; 
Origin of, 50 ; Reaction with Hydrochloric Acid and 
with Ammonia. 49; Hoppe Sevier's Views, 50; Solu- 
bility. 49: Spectrum, 49. 
Urochrom. ...... 50 

Urozrythrix (Harley's Urohaematin) — When Present, 
82, 83 ; Chemical Composition of, 82 ; How to Detect, 
S3 ; How to Differentiate from Blood-Coloring Mat- 
ter. S3: in Acute Articular Rheumatism, 171; in 
Chronic Diseases of the Liver, 173. 
Uroglaucix, ...... 57 

TTroelematix. . . . . . 50, 82 

Uropiueix, ...... 50 

Uroscopy — Development of, by Raver and Becquerel, 5 

Uroxaxthix, ...... 51 

Urrhodix, ...... 51 



Vas Afferexs Glomeruli. 

Vas Efferexs Glomeruli. 

Vex.e Stellat.e. 

Venous Trunks — Formation of, 

Vexulj: Rectje, 

Vibrioxes — in Nephrophthisis, . 

Villous Caxcer — Description of, 

Tissue, ..... 
Vogel's Approximate Quantitative Test 

Nomenclature for Bacteria, . 

Westphal — Scales of, 

Xaxthix. .... 

Yeast Fungi — in Diabetic Urine, 
Quantity of, 55 ; Tests for, 55, 56. 



for Sugar — 



13 
13 

14 

14 

14 

204 

133 

217 

128 

24 

129 

172 









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